Death during hospitalization in patients on chronic hemodialysis

Mortality from various causes is higher in patients on chronic hemodialysis (HD) than in the general population. There is evidence suggesting that some of the deaths in HD patients are preventable. To identify potentially preventable causes of death, we analyzed deaths that occurred in HD patients during hospitalization over a period of 15 years. We performed a retrospective cohort analysis of 410 patients on HD for at least 6 months between 1995 and 2009 (included), who had all their hospitalizations in the same hospital. The patients were classified into 3 groups: Those who died during hospitalization (group A, n=120), those who died away from the hospital (group B, n=135), and those who were alive at the end of the observation period (group C, n=155). Continuous variables were compared between groups by the Kruskall-Wallis statistic. Logistic regression was used to identify predictors of dying during the observation period and predictors of death in the hospital. For the whole HD group of 410 patients, only 9 (2.2%) were women. 59% of the patients had diabetes mellitus. Age at the onset of HD was 65.8 ± 11.5 years and the duration of HD was 34.4 ± 27.9 months. Group A patients had a higher annual rate and duration of hospitalization and a higher Charlson comorbidity index than either of the other 2 groups, and, in comparison with patients in group C, were older at the end of observation and had a shorter duration of HD. Cardiac disease (19.2%), vascular access complications (18.3%), peripheral vascular disease (16.7%), infections (15.8%), trauma (11.7%), central nervous system disease (7.5%), respiratory failure (4.2%), malignancy (3.3%), and gastrointestinal disease (3.3%) were the causes of the last hospitalization in group A. Compared with the patients who died during hospitalization without discontinuing HD, group A patients who discontinued HD had a longer duration of their last hospitalization (52.7 ± 77.7 vs. 14.3 ± 23.8 days, P<0.001). Discontinuation of HD occurred in 80% of the hospitalizations for respiratory failure, 75% of the hospitalizations for malignancy, 57% of the hospitalizations for trauma, and 56% of the hospitalizations for central nervous system disease. Logistic regression identified a high Charlson index, advanced age, and short duration of HD as predictors of death, and an absence of diabetes, high Charlson index, prolonged annual duration of hospitalization, and short distance of the patient's domicile from the dialysis unit as predictors of death in the hospital. A substantial number of hospitalizations leading to the death of HD patients are caused by potentially preventable conditions, including vascular access complications, peripheral vascular disease, and trauma. Implementation of measures preventing these hospitalizations is a worthwhile undertaking.     

Sertraline can reduce uremic pruritus in hemodialysis patient: A double blind randomized clinical trial from Southern Iran

Introduction: Uremic pruritus is an undesirable complication of end stage renal disease (ESRD). In spite of introduction of many treatments for this complication, it has no certain cure. The aim of this study was to assess sertraline effect on uremic pruritus. Methods: In the present clinical trial study, we randomly divided our patients into two groups; trial group that received sertraline and control group that consumed placebo. We measured the severity of pruritus by two scoring systems (visual analogue scale and DUO) at the beginning and during the study with a‐2‐week interval. Data were analyzed by SPSS 18.0 and a P value < 0.050 considered as significant. Findings: The mean age of our patients was 44.1 ± 16.1 years. Pruritus intensity significantly decreased in both groups (P < 0.001) and both scoring systems. Although the amount of decrease in trial group was significantly more than control group (P < 0.001). We found a direct relation between blood urea nitrogen and phosphorus and the degree of itching in VAS system (P < 0.009). There was a reverse significant relation between itching and calcium in both scoring systems (P < 0.012). Also pruritus intensity was directly correlated with C‐reactive protein in both scoring systems (P < 0.05). Discussion: Depends on present study and previous ones, inflammation appears to play a significant role in uremic itching. Sertraline is an effective drug in reducing this complaint possibly due to its effect on reducing inflammatory cytokines. In addition there is no need to adjust sertraline dosage in patients with ESRD. Sertraline might be a treatment for patients with ESRD who do not respond to other routine drugs.     

Variability of pulse wave velocity and mortality in chronic hemodialysis patients

We have already demonstrated that in chronic hemodialysis (HD) patients, the cyclic variations in both hydration status and blood pressure are responsible for changes in pulse wave velocity (PWV). The aim of this study is to verify whether the cyclic variation of PWV influences mortality in dialysis patients. We studied 167 oligoanuric (urinary output <500 mL/day) patients on chronic standard bicarbonate HD for at least 6 months. They performed 3 HD sessions of 4 hours per week. Patients were classified into 3 groups: normal PWV before and after dialysis (LL); high PWV before and normal PWV after dialysis (HL); and high PWV before and after dialysis (HH). The carotid-femoral PWV was measured with an automated system using the foot-to-foot method. Analysis of variance was used to compare the different groups. The outcome event studied was all-cause mortality and cardiovascular mortality. The PWV values observed were LL in 44 patients (26.3%); HL in 53 patients (31.8%); and HH in 70 patients (41.9%). The 3 groups of patients are homogenous for sex, age, and blood pressure. The HH group had a higher prevalence of (P<0.001) ASCVD. It is interesting that the distribution of patients in the 3 groups is correlated with the basal value of PWV. In fact, when the basal measure of PWV is elevated, there is a higher probability that an HD session cannot reduce PWV (<12 ms). A total of 53 patients (31.7%) died during the follow-up of 2 years: 5 patients in the LL group (11.4%); 16 in the HL group (30.2%); and 32 in the HH group (50.7%) (LL vs. HL, P=0.047; LL vs. HH, P<0.00001; HL vs. HH, P=0.034). We evidence for the first time that different behaviors of PWV in dialysis subjects determine differences in mortality.     

Malnutrition‐inflammation‐coronary calcification in pediatric patients receiving chronic hemodialysis

Malnutrition, inflammation, and renal osteodystrophy parameters with resultant coronary calcification (CC) are associated with increased cardiovascular mortality in adults. Previous pediatric studies demonstrated CC in children but none assessed for an association between inflammation, malnutrition, renal osteodystrophy, and CC. To assess CC, ultrafast computerized tomogram was obtained for 16 pediatric patients (6 females; median age 17.2 years; range 9.1–21.2 years) receiving hemodialysis for ≥2 months. Inflammation was assessed by serum IL‐6, IL‐8, and C‐reactive protein levels on the day of the computerized tomogram scan; nutrition parameters included serum albumin, cholesterol, the body mass index standard deviation score, and normalized protein catabolic rate. Renal osteodystrophy parameters included time‐averaged serum calcium, phosphorus, total PTH, and calcitriol/calcium dose. Patients received hemodialysis thrice‐weekly; mean single pool Kt/V 1.48±0.13; and mean normalized protein catabolic rate 1.27±0.17 g/kg/day. Five of 16 patients had CC. Patients with CC were older (19.1±2.1 vs. 15.4±3.1 months; P=0.03), had longer dialysis vintage (49.4±15.3 vs. 17.2±10.5 months, P=0.0002), lower serum cholesterol (122±17.7 vs. 160.4±10.6 mg/dL, P=0.02), and higher phosphorus (9.05±1.2 vs. 6.1±0.96 mg/dL, P=0.0001). Mean serum albumin and normalized protein catabolic rate did not differ for patients with CC. All patients had elevated IL‐6 and IL‐8 levels compared with healthy norms; the mean IL‐6, IL‐8, and C‐reactive protein levels were not different in patients with CC. Coronary calcification was prevalent in older children receiving maintenance hemodialysis with a longer dialysis vintage. Worse renal osteodystrophy control and malnutrition (low cholesterol) may contribute to CC development.     

Necrotizing fasciitis and infective endocarditis caused by Escherichia coli in a hemodialysis patient

Patients with uremia are often immunocompromised and uremia patients undergoing maintenance dialysis are often vulnerable to uncommon infections. We report a 40‐year‐old man who was undergoing maintenance hemodialysis and was initially diagnosed with monomicrobal necrotizing fasciitis of the lower limbs, based on blood and pus cultures that yielded Escherichia coli. His condition improved after surgical debridement and antibiotic therapy. However, he eventually died of intracranial hemorrhage related to septic emboli. Concurrent infective endocarditis was diagnosed based on an echocardiogram that indicated vegetation in the left ventricular region. Escherichia coli‐related necrotizing fasciitis and infective endocarditis is rarely seen in clinical practice. There should be a high index of suspicion for multiple infections when a hemodialysis patient presents with an uncommon infection.     

The influence of comorbidity on the risk of access-related bacteremia in chronic hemodialysis patients

Access-related bacteremia is an important cause of morbidity in chronic hemodialysis patients. The incidence of bacteremia is higher in patients dialyzing through a tunneled central venous catheter (TCVC) compared with an arteriovenous fistula (AVF). Our aim was to explore if this is explained by patient comorbidity. Two groups of chronic hemodialysis outpatients were compared: all patients who dialyzed through a TCVC at any time during 2003 and were fit enough to subsequently have a functioning AVF or renal transplant even if it was after 2003 (Group 1; n=93); and all patients who dialyzed through a TCVC in 2003 and were not fit enough to have a functioning AVF or renal transplant (Group 2; n=119). Episodes of bacteremia (n=71) were identified and those not related to access were excluded. Patients in Group 1 were younger than Group 2 (57.5 years vs. 64.8 years; P=0.001). The incidences of bacteremia in Groups 1 and 2 were, respectively, 0.31 and 0.44 episodes per 1000 patient days while dialyzing through an AVF (P=0.77), and 2.21 and 2.27 per 1000 days while dialyzing through a TCVC (P=0.91). The 3-year actual survival from January 1, 2003 to January 1, 2006 was significantly higher in Group 1 than in Group 2 (80.6% vs. 26.1%; P<0.0001) confirming the higher comorbidity of the patients in Group 2. Patients dialyzing through a TCVC (compared with an AVF) have a significantly higher risk of access-related bacteremia, irrespective of comorbidity.     

Changing patterns of pericardial disease in patients with end-stage renal disease

Pericarditis can occur in patients with chronic renal failure before initiation of dialysis. It is also described in established dialysis patients. Traditionally, the cause of pericarditis in such settings has been attributed to uremia and/or inadequate dialysis and it is consequently thought that intensifying the dialysis process in such patients could improve outcome. We report here 7 cases of acute pericarditis in patients with end-stage renal disease on renal replacement therapy. Only 3 of the patients gave any history of chest pain, and a pericardial friction rub was only noted in 2. Despite a period of intensive dialysis, none of the patients improved and all required pericardial drainage as the definitive curative procedure. The clinical presentation of acute pericarditis in dialysis patients therefore may be atypical and pericardial drainage should be considered early, as intensive dialysis alone may not lead to resolution.     

Uremic pruritus: a review

Pruritus is a major disorder among the skin derangements in advanced renal failure. Its prevalence seems to be diminishing perhaps because of improvements in dialysis treatment. Recent information suggests that interactions between dermal mast cells and distal ends of nonmyelinated C fibers may be important in the precipitation and regulation of the sensory stimuli. The knowledge as to the control of pruritus transmission to cortex areas is still incomplete but endogenous opioid and opioid receptors may have a role in this regard. A recent classification was proposed for pruritus based on the level of its origin. Uremic pruritus, however, seems to be too complex to fit perfectly in any of the suggested modalities. Inflammation and malnutrition are recognized risk factors for cardiovascular death in end-stage renal disease patients, which may be related to the genesis of pruritus. Consistent with this concept, lower serum levels of albumin and higher serum levels of ferritin were found in pruritic patients when compared to nonpruritic ones. Newer treatments for this difficult clinical problem are being developed and tested.     

An Overview of Uremic Toxicity

About 100 uremic retention solutes have been identified at present, but not all of these compounds are necessarily toxic. They can be defined as uremic toxins if they exert biochemical/biological actions. Based on their physicochemical characteristics, there are three major groups of uremic retention solutes: 1) the small water‐soluble compounds (<500 Da), which are easily removed by standard low‐pore‐size dialyzer membranes; 2) the protein‐bound solutes (also mostly <500 Da), whose dialytic removal is hampered by their protein binding, irrespective of the membrane type; and 3) the so‐called middle molecules (>500 Da), which can be removed only by membranes with a large pore size and/or adsorptive capacity. In the present review, we will summarize the currently known information about the toxicity of the uremic retention solutes. Although removal of small water‐soluble urea has been recognized for many years as a current measure of dialysis adequacy, data on its toxicity are very scanty. Almost 50 other water‐soluble compounds are known to be retained in uremia, but only a few exert biological effects. Most of the toxic water‐soluble moieties, such as the guanidines, phosphate, xanthine, and hypoxanthine show an intra‐dialytic compartmental behavior, which is different from urea. A substantial number of uremic solutes are protein bound, and most of them exert biological action. Among them are the phenols, indoles, homocysteine, and carboxy‐methyl‐propyl‐furanpropionic acid. Recent data suggest that protein binding acts as a buffer against the toxic effects of these compounds, and that hypoalbuminemia increases both their free fraction and their toxicity. In addition, many middle molecules, such as ß₂‐microglobulin, leptin, and advanced glycation end products, have been related to biological/clinical effects. Our current knowledge of the biological impact of the middle molecules is very likely incomplete. It is concluded that many of the water‐soluble compounds exert little or no toxicity, and that urea removal pattern per se is not identical to that of many biologically active molecules. Hence, in dialysis, more than urea removal alone should be pursued.     

Predictors of anemia in patients on hemodialysis

Even though the use of erythropoietin and intravenous iron has improved the treatment of anemia in hemodialysis patients, a considerable proportion of these patients still have anemia. The aim of this study was to identify predictors of anemia in a hemodialysis population. In a single-center hemodialysis unit, all patients were studied with blood tests and their medication recorded during a period of 22 months. Correlations with hemoglobin (Hb) were performed with a simple regression or a t test. Variables that reached 5% significance were entered in a multiple regression analysis. Selected variables were presented in quartiles with levels of Hb. Mean Hb was 11.3 g/dL, and 53 patients (40%) had Hb<11.0 g/dL. In the simple regression analysis Hb correlated positively with s-iron, CHr, s-albumin, and doses of sevelamer, and negatively with sedimentation rate (SR), ferritin, base excess, and doses of erythropoietin. In the multiple regression analysis erythrocytes SR was the only variable that remained significant. Elevated SR is the strongest predictor of anemia in hemodialysis patients receiving adequate treatment with erythropoietin and intravenous iron. Patients using high doses of sevelamer had higher Hb levels than patients using low doses.     

Tuberculosis in patients on hemodialysis in an endemic region

Clinical presentation of tuberculosis is different in hemodialysis patients than in the general population. This study aimed to analyze hemodialysis patients with tuberculosis in Istanbul. Patients who were on a chronic hemodialysis program in Istanbul for more than 3 months and diagnosed to have tuberculosis at least 3 months after the start of hemodialysis were included. To discard the effect of immigration from other cities, we included only patients who had started their dialysis program in Istanbul. Their demographic and clinical data were analyzed using Statistical Package for Social Sciences for Windows ver. 13.0. Of the 925 patients screened from 7 different centers, 31 (3.35%) were found to have tuberculosis. The mean age was 52.3±13.5 years. The male/female ratio was 18/13. The mean duration of dialysis therapy and the duration of dialysis till the diagnosis of tuberculosis were 62.6±54.3 and 21.7±25.7 months, respectively. Extrapulmonary tuberculosis constituted 48.39%. Treatment ended with a cure in 18 (58.05%); was still ongoing in 12 (38.70%) patients; and 1 (3.25%) died of pulmonary tuberculosis. The lower incidence of tuberculosis compared with previous reports may be related to the differences in the diagnostic criteria and the decrease in the rate of tuberculosis during recent years. The demographic and clinical parameters of the patients were quite similar to the average dialysis population in Turkey. Hence, we cannot address a subpopulation with additional risk. It is important to prevent tuberculosis in hemodialysis patients due to difficulties in the diagnosis and treatment. Thus we recommend routine screening of hemodialysis patients and effective isolation and treatment of infected patients.     

P-selectin, E-selectin, and CD40L over time in chronic hemodialysis patients

The aim of this study was to measure P-selectin, E-selectin, and CD-4L levels over time in chronic hemodialysis (HD) patients. Thirty stable patients with end-stage renal failure undergoing chronic HD were included in the study. Blood samples were obtained before HD for measurement of P-selectin, E-selectin, and CD-40L. Measurements were performed at month 0 (T0), 3 (T2), 8 (T3), and 13 (T4). The levels of P-selectin, E-selectin, and CD40L were also analyzed according to the occurrence of cardiovascular disease (CVD) and to CVD-related mortality. The levels of CD40L and P-selectin changed significantly over time, decreasing at month 3 and 6 and returning at the T0 levels at month 13. Conversely, E-selectin levels did not. The levels of CD40L, P-selectin and E-selectin over time did not differ significantly between patients with age ≤ 65 or > 65 years, between patients with or without CVD, or between patients who died or who survived during the follow-up. In end-stage renal failure patients undergoing chronic HD, CD40L and P-selectin, but not E-selectin, showed a transient decrease over time, and the serum levels of these molecules were not associated with CVD or with CVD-related mortality.     

Complication of diagnostic pleural aspiration: Is it of value in hemodialysis patients?

Pleural effusions are common in hemodialysis patients and are associated with significant morbidity. Diagnostic pleural aspiration and subsequent biochemical analysis can be used to differentiate exudates and transudates. In particular, Light's criteria have been validated in the general population although their efficacy in hemodialysis patients is unclear. Furthermore, aspiration is not without risk; we report the case of a life‐threatening thoracic bleed as a complication of diagnostic thoracocentesis in a hemodialysis patient, in whom a transudative effusion was misclassified according to Light's criteria. Retrospective examination of a further 22 aspirations in hemodialysis patients suggests that biochemical analysis of pleural fluid in this group is of limited value. Careful clinical and radiological assessment may be of greater value in determining individuals who may benefit from formal drainage, rather than diagnostic aspiration with its attendant risks.     

Survival pattern of hemodialysis patients in Kumasi, Ghana: A summary of forty patients initiated on hemodialysis at a new hemodialysis unit

To evaluate the survival pattern of hemodialysis patients at a dialysis unit in Kumasi, Ghana, through a retrospective (observational) study. Patients who were placed on hemodialysis at the dialysis unit at Komfo Anokye teaching hospital from October 25, 2006 to December 2007. The patients were followed from initiation of dialysis until December 31, 2007. The overall mortality was 14 (35.9%) on the incident population for the period and that for the first 90 days was 12 (32.4%) patients. Chronic glomerulonephritis was the underlying kidney disease in 35.9%. This was followed by hypertension (19.1%) and diabetes mellitus (15.4%), respectively. Cardiovascular diseases accounted for 42% of mortality. This was followed by septicemia (25%) from the access site and anemia (25%). Fifty percent of the patients were able to afford 20 sessions of hemodialysis before stopping. The most powerful predictors of survival were the duration of hemodialysis (P=0.05) and the number of hemodialysis sessions (P=0.02). Age at initiation of hemodialysis was not significant. First 90-day mortality of patients on hemodialysis is high in poor African countries. This is due partially to the late referral of patients and also the cost of the dialysis treatment. Efforts will have to be made to reduce the cost of the dialysis treatment. Reuse technology (of dialyzer, etc.) should be introduced to cut down the cost of hemodialysis. Peritoneal dialysis should also be introduced for highly motivated patients. Efforts should also be made to reduce the increasing incidence of kidney disease, and finally third-world countries should consider establishing kidney transplantation, that is cost effective.     

Initial clinical experience with a new heparin-coated chronic hemodialysis catheter

In this paper we wish to report our clinical experience with a new heparin-coated dialysis catheter with a symmetric tip. Over a 16-month period, 60 heparin-coated Tal Palindrome^™ catheters were placed in 57 patients. Catheter patency, catheter-related complications, and reasons for catheter removal were recorded. The patient's initial cause of end-stage renal disease, underlying diseases, and site of access were recorded as well. Patients were specifically followed for development of heparin-induced thrombocytopenia. Patient ages were 34–91 (average 66). Fifty-four percent of patients had a history of diabetes. Sixty catheters were placed for a total of 5353 catheter-days. The average catheter indwell time was 107 days (range of 2–381 days). Catheter-related infection occurred in 6 patients over the study period, with a rate of 1.12/1000 catheter-days. Bacteremia occurred in 3 patients with a rate of 0.56/1000 catheter-days. Six catheters were removed or exchanged due to malfunction. There was no incidence of heparin-induced thrombocytopenia. Initial clinical experience with the heparin-coated Tal Palindrome^™ hemodialysis catheter demonstrated safe, reliable use, and low infection rates.     

Mini mental status examination (MMSE) in stable chronic renal failure patients on hemodialysis: The effects of hemodialysis on the MMSE score. A prospective study

Cognitive impairment is common in hemodialysis (HD) patients. The mini mental status examination is a simple screening test for dementia. The objectives of this study were to (1) study and compare the predialysis and postdialysis mini mental status examination score and 2 subscores and compare them with those of a control group and (2) determine the factors affecting these scores. This was a prospective study of 54 HD patients, which involved calculation of their predialysis (PrHDSc) and (2–4 weeks later) postdialysis (PoHDSc) scores and comparison of these with the control scores (CoSc). The mean scores for PreHDSc and PoHDSc were 26.5±2.7 and 26.4±3.3, respectively. Both were significantly lower than CoSc, 28.4±1.6 (95% CI for score difference 0.99–2.97, P<0.001). The subscores for orientation, registration, and recall (ORR) and attention (ATT) before and after HD were 14.2±1.3, 14.3±1.8, and 3.5±1.7, 3.2±1.8, respectively. Both were significantly lower than the CoSc, 15.2±1.2 and 4.2±1.1 (P=0.001 and 0.004, respectively). There were no significant differences between the PrHDSc and PoHDSc (P values of 0.87, 0.63, and 0.45, respectively). Patients' PrHDSc correlated positively with PoHDSc and dialysis efficiency measured by the urea reduction ratio and Kt/V (r=0.58, 0.4, and 0.34, respectively). Education level correlated positively with PrHDSc r=0.41 but not PoHDSc. Hemodialysis duration correlated negatively with PrHDSc r=−0.3. There was no correlation among age, chronic renal failure duration, HD frequency, weight loss, systolic or diastolic blood pressure drop, and PrHDSc or PoHDSc. Hemodialysis patients scored significantly less than the control patients. Their score was not affected by HD. This may reflect the stable cognitive function/dysfunction or the mild sensitivity of the test.     

Occult hepatitis B among patients with chronic renal failure on hemodialysis from a capital city in northeast Brazil

Occult hepatitis B (OHB) is characterized by the presence of HBV‐DNA in the absence of HBsAg in the serum of patients. Hemodialysis patients are at high risk for hepatitis B virus and there are few data on the prevalence of OHB in this population, mainly in Brazil. Thus, the aim of this study was to determine the prevalence of OHB in patients undergoing hemodialysis. A cross‐sectional study was performed, including 301 patients on chronic hemodialysis at two dialysis centers in São Luís (Maranhão), northeast Brazil. Serological tests were performed for HBsAg, anti‐HBc, anti‐HBs, and anti‐HCV using enzyme immunoassays (ELISA); HBV‐DNA and HCV‐RNA were studied by real‐time PCR. The mean age was 49 ± 15 years, and 128 (42%) were female. Serological tests confirmed that all samples were HBsAg negative. Anti‐HBc was positive in 114 (38%) patients, anti‐HBc and anti‐HBs were simultaneously positive in 104 (35%), and anti‐HBc alone was positive in 10 (3%). Tests were negative for anti‐HBc and anti‐HBs in 55 patients (18%). Anti‐HBs was the only positive marker in 132 (44%) patients. Anti‐HCV was positive in 15 (5%) patients with HCV‐RNA present in 14 of them (93%). HBV‐DNA was positive in seven cases (2.3%). There was no association of HBV‐DNA with age, gender, time on dialysis, previous kidney transplant, or HBV serological pattern, but there was a positive correlation with the presence of anti‐HCV (P < 0.001). OHB in chronic renal failure patients on hemodialysis appears to be a relevant finding, suggesting that studying HBV‐DNA in this population using sensitive molecular tests should be a recommended course of action, especially in candidates for renal transplant.     

Endotoxins and inflammation in hemodialysis patients

Long‐term endotoxin challenge may promote frequent complications in dialysis patients, namely malnutrition, chronic inflammation, and atherosclerosis, which are recognized as the so‐called MIA syndrome. Circulating soluble vascular cell adhesion molecule‐1 (sVCAM‐1) levels may be used to determine the stage of atherosclerosis. This study aimed to assess endotoxin level in hemodialysis (HD) patients and its role in inducing inflammation. The study was conducted on 50 HD patients, chosen from four dialysis centers in Alexandria. Serum blood samples were collected for the determination of albumin and C‐reactive protein (CRP), and whole blood samples were used for the measurement of hemoglobin level. A heparinized whole blood sample was taken postdialysis for endotoxin assay by limulus amebocyte lysate test, and in addition to sVCAM‐1 was estimated using enzyme‐linked immunosorbent assay. The mean endotoxin level was 76.30 pg/mL;80% exhibited values higher than 60 pg/mL. Half the studied patients had CRP values that exceeded the upper limit of the laboratory reference range (<6.0 mg/L). A statistically significant correlation was found between endotoxin and CRP levels (r = 0.47, P = 0.001). The mean pre‐HD level of VCAM was 1851.00 ng/mL, while the mean post‐HD level was 2829.00 ng/mL with statistically significant correlation (r = 0.354, P = 0.012) and it also correlated significantly with endotoxin as well as CRP levels. Endotoxemia may play an important role in the aggravation of endothelial dysfunction in HD patients as indicated by the post‐HD rise in sVCAM‐1.