From lifecycle assessment to decision support: An exploratory framework for environmental impact assessment of peritoneal dialysis systems

Healthcare systems are increasingly recognized as significant contributors to environmental burdens; however, conventional lifecycle assessment (LCA) primarily quantifies impacts and offers limited insight into the complex interactions influencing sustainability-related decisions. This study presents a scenario-based LCA of peritoneal dialysis (PD) delivery systems and explores the integration of LCA with dynamically calibrated Fuzzy Cognitive Mapping (FCM) as a systems-oriented framework. The framework is applied to PD delivery systems in Vancouver, Canada, comparing automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD). Environmental impacts are assessed using the ReCiPe 2016 midpoint method across full lifecycle stages, including consumables production, transportation, and waste treatment. Multiple scenarios are developed to capture variations in clinical prescription, consumables manufacturing, transportation logistics, and service delivery pathways. Results indicate that APD with standard prescription exhibits the highest total climate change impact (35%), followed by APD incremental (25%), CAPD standard (22%), and CAPD incremental (16%). Across all scenarios, consumables production (>51%) and transportation (>42%) are the dominant contributions, highlighting upstream supply-chain processes as key intervention points. The exploratory calibrated FCM analysis identifies consumables material composition and landfill disposal as influential system components. It ranks CAPD incremental with fully virtual follow-up visits as environmentally favorable pathways under the evaluated system conditions, where clinically appropriate. These findings show that scenario-based LCA can identify clear environmental hotspots, while calibrated FCM provides an exploratory systems perspective for interpreting environmental interactions, identifying influential system components, and exploring potential mitigation opportunities within the PD system.