Hemodialysis‐induced changes in the blood composition affect function of the endothelium

Hemodialysis induces oxidative stress causing intravascular inflammation, which may cause endothelial dysfunction. We evaluated how hemodialysis‐induced changes in blood affect the function of endothelial cells in in vitro culture. Serum samples were collected from 42 uremic patients treated with hemodialysis, one before the start of dialysis and the other one at the end of session. All patients were dialysed with polysulfone dialyzer. Concentrations of the inflammatory molecules carbonyl protein and metabolites of NO synthesis were measured in blood. Additionally, the effect of the serum obtained before and after dialysis on the function of endothelial cells in in vitro culture was studied. Hemodialysis caused increase of monocyte chemoattractant protein (MCP)‐1 (+17%), hepatocyte growth factor (+91%), and pentraxin‐3 (+30%) concentration in serum. Concentration of carbonyl protein was decreased by 30%. Decrease of blood level of asymmetric dimethylarginine (?25%) and nitrate/nitrites (?62%) was observed. Serum obtained after hemodialysis stimulated proliferation of endothelial cells (+10%) and synthesis of MCP‐1(+11%) in these cells. Hemodialysis‐induced intravascular inflammation changes the function of endothelial cells, which may lead to acceleration of atherosclerosis.     

Beneficial effects of nocturnal hemodialysis in a hemodynamically unstable patient with AL‐amyloidosis

We present a patient with primary systemic AL‐amyloidosis, who stabilized hemodynamically on nocturnal hemodialysis (NHD). The NHD allowed a significant reduction in ultrafiltration rates which likely underlies the procedural tolerability. It also provided an increase in urea clearance, better control of serum phosphorus levels without the use of any binders, and normalization of blood pressure despite the discontinuation of all antihypertensive agents. Given the autonomic derangements associated with AL‐amyloidosis pathophysiology and the clinical benefits of NHD on hemodynamic stability, the use of intensive hemodialysis may be considered for the management of patients with unstable hemodynamic profiles.     

Impact of advanced dialysis technology on the prevalence of dialysis‐related amyloidosis in long‐term maintenance dialysis patients

Dialysis‐related amyloidosis (DRA) is a unique type of amyloidosis (beta‐2 microglobulin) predominantly in end‐stage renal disease. Its clinical manifestations add to increased morbidity and reduced quality of life. There seems to be a relative risk reduction in DRA manifestations when hemodialysis (HD) patients are treated with advanced HD technology, but changes of the course of DRA are uncertain. The aim of our investigation was to evaluate the prevalence and severity of carpal tunnel syndrome (CTS) in long‐term dialysis patients receiving either conventional or high‐flux, online‐produced ultrapure dialysis fluid. The cross‐sectional study included 147 HD patients (at least 10 years). The definitive diagnosis of CTS was made histologically or by the coexistence of CTS with other radiological DRA manifestations (bone cysts, arthropathies). The two HD patient groups did not differ significantly in age at start of HD, gender, major co‐morbid diseases, anuria, and dialysis vintage. The conventional HD group had significantly higher circulating beta‐2 microglobulin and C‐reactive protein (CRP) levels. The prevalence of DRA was 68% for the conventional HD group and 28% for the advanced HD group. Duration of dialysis treatment was the only significant risk factor for the development of clinical DRA manifestations in both study groups, but CTS, bone cysts, or arthropathies occurred significantly earlier in conventional HD patients. The prevalence and severity of DRA have decreased with advances in dialysis technology during the last two decades, although its occurrence is simply delayed.     

Comparison of alteplase (tissue plasminogen activator) high‐dose vs. low‐dose protocol in restoring hemodialysis catheter function: The ALTE‐DOSE study

Hemodialysis catheter (HDC) dysfunction due to thrombosis is common, and dysfunction incidence can reach up to 50% within 1 year of use. Although administration of intraluminal alteplase (tissue plasminogen activator [tPA]) is the standard of practice to pharmacologically restore HDC function, there are no evidence‐based guidelines concerning the optimal tPA dose. The purpose of this study was to compare the efficacy of 1.0‐mg vs. 2.0‐mg tPA dwell protocols in restoring the HDC function in thrombotic dysfunctional catheters. A retrospective, single‐center study was conducted on two independent cohorts of patients; the first (n = 129) received 2.0 mg tPA/catheter lumen, while the second (n = 108) received 1.0 mg tPA/catheter lumen. Kaplan–Meier and Cox regression analyses were performed to compare the catheter survival time between patients who received 1.0 mg tPA and those who received 2.0 mg tPA. Catheter removal occurred in 25 (19.4%) of those catheters treated with 1.0 mg tPA compared with 11 (10.2%) of catheters treated with 2.0 mg tPA (P = 0.05). The hazard ratio (HR) for catheter removal was 2.75 (95% confidence interval [^95%CI] = 1.25–6.04) for the 1.0‐mg tPA cohort compared with the 2.0‐mg tPA cohort. Correction added on 3 December 2012, after first online publication: The tPA cohort values were changed. Female gender (HR = 2.51; ^95%CI = 1.20–5.27) and age (HR = 0.96; ^95%CI = 0.94–0.98) were also associated with catheter survival. Our findings suggest that treatment of dysfunctional HDC with 2.0‐mg tPA dwells is superior to 1.0‐mg tPA dwells.     

Deep chest X‐ray: Detection and classification of lesions based on deep convolutional neural networks

We investigated whether a convolutional neural network (CNN) can enhance the usability of computer‐aided detection (CAD) of chest radiographs for various pulmonary abnormal lesions. The numbers of normal and abnormal patients were 6055 and 3463, respectively. Two radiologists delineated regions of interest for lesions and labeled the disease types as ground truths. The datasets were split into training, tuning, and testing as 7:1: 2. Total test sets were randomly selected in 1214 normal and 690 abnormal. A 5‐fold, cross‐validation was performed on our datasets. For the classification of normal and abnormal, we developed a CNN based on DenseNet169; for abnormal detection, The You Only Look Once (YOLO) v2 with DenseNet was used. Detection and classification of normal and five classes of diseases (nodule[s], consolidation, interstitial opacity, pleural effusion, and pneumothorax) on chest radiographs were analyzed. Our CNN model classified chest radiographs as normal or abnormal with an accuracy of 97.8%. For the results of the abnormal, F1 score, was 75.2 ± 2.28% for nodules, 55.0 ± 4.3% for consolidation, 78.2 ± 7.85% for interstitial opacity, 81.6 ± 2.07% for pleural effusion, and 70.0 ± 7.97% for pneumothorax, respectively. In addition, we conducted the experiments between our method and RetinaNet with only nodules. The results of our method and RetinaNet at cutoff‐0.5 in the free response operating characteristic curve were 83.45% and 80.55%, respectively. Our algorithm demonstrated viable detection and disease classification capacity and could be used for CAD of lung diseases on chest radiographs.     

Comparison of Staff‐Assisted Home Hemodialysis with In‐Center Hemodialysis and In‐Hospital Hemodialysis

Home hemodialysis (HHD) is superior to in‐center hemodialysis (ICHD) in terms of survival, quality of life, and cost‐effectiveness. However, assistance from family members in performing HHD is not always available to patients, and professional assistance for HHD can be cost prohibitive. For certain patients, ICHD can be impractical due to difficulties in transportation, which may necessitate ambulance transportation or hospitalization for in‐hospital hemodialysis (IHHD). We describe 4 patients that have had problems receiving ICHD for various reasons. Two of these patients had problems with transportation, while the other two could not remain on dialysis for the prescribed duration of time and, therefore, received inadequate dialysis. These patients had difficulty while receiving ICHD in meeting the adequacy criteria set by Dialysis Outcomes Quality Initiative. One of these patients had a neuropsychiatric disorder and displayed disruptive behavior. When these 4 patients were switched to staff‐assisted home hemodialysis (SAHD), the dialysis core indicators improved compared with ICHD, and the patients needed significantly fewer hospitalization days. In this paper, we demonstrate that, in patients that cannot be easily transferred, and in patients with neuropsychiatric disorders, SAHD can be a less expensive and more efficacious modality of dialysis.     

Hyperprolactinemia in end‐stage renal disease and effects of frequent hemodialysis

Introduction: End‐stage renal disease is associated with elevations in circulating prolactin concentrations, but the association of prolactin concentrations with intermediate health outcomes and the effects of hemodialysis frequency on changes in serum prolactin have not been examined. Methods: The FHN Daily and Nocturnal Dialysis Trials compared the effects of conventional thrice weekly hemodialysis with in‐center daily hemodialysis (6 days/week) and nocturnal home hemodialysis (6 nights/week) over 12 months and obtained measures of health‐related quality of life, self‐reported physical function, mental health and cognition. Serum prolactin concentrations were measured at baseline and 12‐month follow‐up in 70% of the FHN Trial cohort to examine the associations among serum prolactin concentrations and physical, mental and cognitive function and the effects of hemodialysis frequency on serum prolactin. Findings: Among 177 Daily Trial and 60 Nocturnal Trial participants with baseline serum prolactin measurements, the median serum prolactin concentration was 65 ng/mL (25th–75th percentile 48–195 ng/mL) and 81% had serum prolactin concentrations >30 ng/mL. While serum prolactin was associated with sex (higher in women), we observed no association between baseline serum prolactin and age, dialysis vintage, and baseline measures of physical, mental and cognitive function. Furthermore, there was no significant effect of hemodialysis frequency on serum prolactin in either of the two trials. Discussion: Serum prolactin concentrations were elevated in the large majority of patients with ESRD, but were not associated with several measures of health status. Circulating prolactin levels also do not appear to decrease in response to more frequent hemodialysis over a one‐year period.     

Survival with short‐daily hemodialysis: Association of time,site, and dose of dialysis

In thrice‐weekly hemodialysis, survival correlates with the length of time (t) of each dialysis and the dose (Kt/V), and deaths occur most frequently on Mondays and Tuesdays. We studied the influence of t and Kt/V on survival in 262 patients on short‐daily hemodialysis (SDHD) and also noted death rate by weekday. Contingency tables, Kaplan‐Meier analysis, regression analysis, and stepwise Cox proportional hazard analysis were used to study the associations of clinical variables with survival. Patients had been on SDHD for a mean of 2.1 (range 0.1–11) years. Mean dialysis time was 12.9 ± 2.3 h/wk and mean weekly stdKt/V was 2.7 ± 0.5. Fifty‐two of the patients died (20%) and 8‐year survival was 54 ± 5%. In an analysis of 4 groups by weekly dialysis time, 5‐year survival continuously increased from 45 ± 8% in those dialyzing <12 hours to 100% in those dialyzing >15 hours without any apparent threshold. There was no association between Kt/V and survival. In Cox proportional hazard analysis, 4 factors were independently associated with survival: age in years Hazard Ratio (HR)=1.05, weekly dialysis hours HR=0.84, home dialysis HR=0.50, and secondary renal disease HR=2.30. Unlike conventional HD, no pattern of excessive death occurred early in the week during SDHD. With SDHD, longer time and dialysis at home were independently associated with improved survival, while Kt/V was not. Homedialysis and dialysis 15+ h/wk appear to maximize survival in SDHD.     

Survival and other clinical outcomes of maintenance hemodialysis patients in Taiwan: A 5‐year multicenter follow‐up study

The increasing aging and diabetes mellitus (DM) patients in dialysis population make the quality maintenance of dialysis an imperative issue. Recently, an increasing number of dialysis centers were run by private dialysis providers, many of which apply quality assurance programs and performance management systems to dialysis care. We studied patients in dialysis facilities in Taiwan run by a private chain to see clinical outcomes of centers operating under these systemic strategies. Hemodialysis patients from January 1, 2008 to December 31, 2012 in 25 dialysis facilities in Taiwan, which received the management and consultation from a dialysis service provider, NephroCare (NC), were included. Data pivotal to quality of dialysis were analyzed. During a 5‐year interval, 5161 hemodialysis patients were included. For volume control, the proportion of patients with weight gain ≥4.5% decreases from 41.7% to 30.2%. Mean Kt/V is 1.74 ± 0.28. Mean albumin level is 3.92 ± 0.38 g/dL. Patients with phosphate <5.5 mg/dL is up to 71.8%. The mean hemoglobin level is 10.70 ± 1.40 g/dL. More than 80% of patients have adequate iron status. Further, 73% of patients use native arteriovenous fistula. Hospitalization‐free survival rate was 56% at the fifth year. Patient survival rate at the fifth year was 66.4%. Overall clinical performances were maintained very stable in NC facilities from this temporal data analysis. The hospitalization and survival rate also compare favorably with those reported internationally. These results warrant further studies to justify the application of this kind of quality assurance programs and performance management systems in dialysis care.     

Use of 3‐hour daily hemodialysis and paricalcitol in patients with severe secondary hyperparathyroidism: A case series

Patients with poor metabolic control receiving conventional hemodialysis are at risk for developing severe secondary hyperparathyroidism. We postulated that daily hemodialysis may be effective at controlling parathyroid hormone (PTH) in the setting of severe secondary hyperparathyroidism by improving the control of hyperphosphatemia and allowing increased use of vitamin D analogs. We present 5 patients with severe secondary hyperparathyroidism (median iPTH=1783 pg/mL) who were treated with 3‐hour daily hemodialysis (3 hours × 6 times a week). Daily hemodialysis, at 1 year, was associated with a 70.4% reduction in median PTH (1783 pg/mL [interquartile range: 1321–1983]–472 pg/mL [334, 704], P<0.001). Additionally, there was an increase in paricalcitol dose from 0 mcg/d to 10.8 (2.00, 11.7) mcg/d, a 39% reduction in calcium × phosphorus product (80.3 ± 26.8–48.9 ± 14.0, P<0.01), a 52% reduction in serum phosphorus (9.90 ± 2.34–4.75 ± 0.79 mg/dL, P<0.0001), and a 17.6% increase in serum calcium (8.18 ± 2.04–9.62 ± 0.93 mg/dL, P<0.01). Three‐hour daily hemodialysis with the use of high‐dose paricalcitol is associated with improved control of severe secondary hyperparathyroidism.     

A meta‐analysis of sodium profiling techniques and the impact on intradialytic hypotension

Introduction Hemodialysis has improved in recent years, however, despite such improvements, intra‐dialytic hypotensive episodes still persist which can lead to a reduction in the overall effectiveness of the treatment. Profiling sodium levels during dialysis can improve vascular refilling and therefore may prevent hypotensive events. A number of profiling methods exist and this meta‐analysis set out to examine the effectiveness of these methods. Methods To assess the effectiveness of hemodialysis sodium profiling techniques. A review and meta‐analysis analytical framework was used. A search was conducted using Medline, Embase and CINAHL, Scopus and Web of Knowledge between 1946 and 2014 of published English‐language peer reviewed randomized control studies. In total 10 articles were retrieved and included in the review. All data was abstracted with a standardized data collection form. Stata 11.2 (Stata Corp) was used to analyse the data. Actual numbers of hypotensive events were pooled between studies. Analysis of subgroups was performed on sodium profile type. The data were further investigated using meta‐regression. Publication bias was also tested. Findings Stepwise profiling was shown to be statistically significantly effective in reducing intradialytic episodes. Results demonstrated that linear sodium profiling was not effective in reducing hypotensive events during dialysis. Discussion This review has shown that using stepwise profiling is more effective at reducing intra‐dialytic symptoms than other profiling methods. There was no evidence that linear profiling method was any more effective than conventional dialysis and in fact the results showed the reverse.     

An efficient method for estimating soft tissue deformation based on intraoperative stereo image features and point‐based registration

Estimation of soft tissue deformation occurring during image‐guided surgery using an easily implemented and accurate method is necessary. Using a stereo camera, this study focuses on two efficient methods for estimating soft tissue deformation. Two methods were proposed to overcome limitations associated with the typical methods used for estimating soft tissue deformation, such as dependence on accuracy of the operator and indentation of skin. The first method is based on Triclops SDK, and the second method is based on projecting a pattern to acquire P‐Lands (Projected Landmarks). Based on the proposed methods, surface information is acquired in the form of point clouds of surface point coordinates to the submillimeter accuracy. The reconstructed predeformation three‐dimensional (3D) point cloud obtained for each method is registered with a modified iterative closest point algorithm to a postdeformation 3D point cloud obtained from the same region of interest. Results were compared with an MRI–MRI registration method as a control. Results are provided as RMS differences between the initial and final coordinates of corresponding points. The average RMS difference for the typical method is 3.53 mm, that for the Triclops SDK method is 2.32 mm, and that for the P‐Lands projection method is 2.06 mm. The MRI‐MRI registration had an average RMS difference of 1.12 mm. Using MRI‐MRI registration as the gold standard, the average error obtained for the typical method was 2.41 mm, that for the first method was 1.2 mm, and that for the second method was 0.94 mm. © 2013 Wiley Periodicals, Inc. Int J Imaging Syst Technol, 23, 294–303, 2013     

Inappropriately elevated endothelin‐1 plays a role in the pathogenesis of intradialytic hypertension

The aim of this study is to investigate the effects of endogenous vasoactive substances on the occurrence of intradialytic hypertension (IDH) in patients during maintenance hemodialysis. Thirty‐four maintenance hemodialysis patients were enrolled in this trial, and 17 of them were diagnosed with IDH (defined as an increase in blood pressure of at least 10 mmHg during or immediately after a hemodialysis session), while 17 age‐matched and sex‐matched controls without IDH were selected for a retrospective comparison. We collected patients' blood samples before and after a dialysis session and measured the plasma levels of N‐terminal fragment brain natriuretic peptide, renin, angiotensin‐II, aldosterone (ALD), angiotensin‐converting enzyme (ACE), endothelin‐1 (ET‐1), nitric oxide (NO), norepinephrine (NOR), and adrenomedullin. The post‐dialysis serum ET‐1 concentrations were significantly higher (4.09 ± 2.06 vs. 2.75 ± 1.34 pg/mL, P < 0.05), while the post‐dialysis ratio of NO to ET‐1 was lower (17.79 ± 5.65 vs. 24.78 ± 12.04, P < 0.05) in IDH patients compared with the control group. Post‐dialysis ALD and NOR values were significantly lower (P < 0.01) and ACE levels were significantly higher (P < 0.01) than the pre‐dialysis concentrations only in the control and not in the IDH group. All other measured factors did not differ significantly between the groups and between pre‐dialysis and post‐dialysis determinations. Compared with blood angiotensin‐II, ALD, ACE, NOR, adrenomedullin, N‐terminal fragment brain natriuretic peptide, and NO status, inappropriately elevated ET‐1 plasma concentrations may play a predominant role in the pathogenesis of IDH.     

Effects of silymarin on biochemical and oxidative stress markers in end‐stage renal disease patients undergoing peritoneal dialysis

Introduction End‐stage renal disease (ESRD) patients especially those undergoing dialysis are vulnerable to several complications, in particular those related to oxidative stress. Silymarin is an herbal medicine commonly used as an antioxidant in different pathologies. Methods To evaluate the effect of silymarin on biochemical and oxidative stress markers, 50 ESRD patients undergoing peritoneal dialysis were randomly divided into two groups of silymarin (n = 28) and control (n = 22) and received silymarin (140 mg every 8 hours) or placebo for 2 months, respectively. Ferric reducing antioxidant power and total 8‐iso‐prostaglandin F_2α were measured in plasma, while catalase enzyme activity was measured in erythrocytes of both groups before and after treatment. Findings Ferric reducing antioxidant power values after treatment were significantly decreased in silymarin group compared to before treatment values (17.2 ± 2.9 and 15.9 ± 3.1 µM equivalent of quercetin/dL, respectively, P < 0.05). Conversely, catalase levels were increased 17.3% after silymarin consumption, while it was decreased 9.1% in control group. Further, hemoglobin (from 10.94 ± 2.17 to 11.54 ± 2.03 g/dL, P < 0.05) and albumin levels (from 3.48 ± 0.67 to 3.61 ± 0.53 g/dL, P < 0.05) were significantly increased after silymarin administration. Discussion It is concluded that silymarin could be regarded as a supplementary therapy for ESRD patients undergoing peritoneal dialysis in order to reduce complications.     

Intermittent hemodialysis treatment in cefepime‐induced neurotoxicity: Case report,pharmacokinetic modeling,and review of the literature

Cefepime is a broad‐spectrum cephalosporin indicated for in‐hospital treatment of severe infections. Acute neurotoxicity, an increasingly recognized adverse effect of this drug in an overdose, predominantly affects patients with reduced renal function. Although dialytic approaches have been advocated to treat this condition, their role in this indication remains unclear. We report the case of an 88‐year‐old female patient with impaired renal function who developed life‐threatening neurologic symptoms during cefepime therapy. She was treated with two intermittent 3‐hour high‐flux, high‐efficiency hemodialysis sessions. Serial pre‐, post‐, and peridialytic (pre‐ and postfilter) serum cefepime concentrations were measured. Pharmacokinetic modeling showed that this dialytic strategy allowed for serum cefepime concentrations to return to the estimated nontoxic range 15 hours earlier than would have been the case without an intervention. The patient made a full clinical recovery over the next 48 hours. We conclude that at least 1 session of intermittent hemodialysis may shorten the time to return to the nontoxic range in severe clinically patent intoxication. It should be considered early in its clinical course pending chemical confirmation, even in frail elderly patients. Careful dosage adjustment and a high index of suspicion are essential in this population.     

Self‐perceived quality of sleep and mortality in Norwegian dialysis patients

Sleep complaints are prevalent and associated with poor health‐related quality of life (HRQoL), depression and possibly mortality in dialysis patients. This study aimed to explore possible associations between sleep quality, daytime sleepiness and mortality in dialysis patients. In this study, 301 dialysis patients were followed up to 4.3 years. HRQoL was evaluated at baseline with the Kidney Disease and Quality of Life—Short Form (KDQoL‐SF), depression with Beck Depression Inventory (BDI), sleep quality with Pittsburgh Sleep Quality Index and daytime sleepiness with Epworth Sleepiness Scale. The single item “on a scale from 0–10, how would you evaluate your sleep?” in the sleep subscale in KDQoL‐SF was used to identify poor (0–5) and good sleepers (6–10). A total of 160 patients (53.3%) were characterized as poor sleepers. They were younger (r = 0.241, P < 0.001), had more depression (BDI: 8.72 ± 6.79 vs. 13.60 ± 8.04, P < 0.001), a higher consumption of hypnotics and antidepressants and reduced HRQoL (Mental Component Summary score: 45.4 ± 11.0 vs. 50.0 ± 10.4, P < 0.001. Physical Component Summary score: 35.0 ± 9.9 vs. 38.5 ± 10.5, P = 0.004). In multivariate analyses, poor sleepers had nearly a twofold increase in mortality risk (hazard ratio [HR] 1.92, confidence interval [CI] 1.10‐3.35, P = 0.022). Daytime sleepiness was not related to mortality (HR 1.01, CI 0.95‐1.08, P = 0.751). Sleep complaints predicted increased mortality risk in dialysis patients and should therefore be routinely assessed. Further studies are needed to find suitable treatment options for poor sleep in dialysis patients as it may affect both HRQoL and survival.     

Effects of end‐stage renal disease and dialysis modalities on blood ammonia level

Introduction: Uremia results in a characteristic breath odor (uremic fetor) which is largely due to its high ammonia content. Earlier studies have shown a strong correlation between breath ammonia and blood urea levels and a 10‐fold reduction in breath ammonia after hemodialysis in patients with chronic kidney disease. Potential sources of breath ammonia include: (i) local ammonia production from hydrolysis of urea in the oropharyngeal and respiratory tracts by bacterial flora, and (ii) release of circulating blood ammonia by the lungs. While the effects of uremia and hemodialysis on breath ammonia are well known their effects on blood ammonia are unknown and were explored here. Methods: Blood samples were obtained from 23 hemodialysis patients (immediately before and after dialysis), 14 peritoneal dialysis patients, and 10 healthy controls. Blood levels of ammonia, creatinine, urea, and electrolytes were measured. Findings: No significant difference was found in baseline blood ammonia between hemodialysis, peritoneal dialysis and control groups. Hemodialysis procedure led to a significant reduction in urea concentration (P < 0.001) which was paradoxically accompanied by a modest but significant (P < 0.05) rise in blood ammonia level in 10 of the 23 patients studied. Change in blood ammonia pre‐ and post‐hemodialysis correlated with change in serum bicarbonate levels (r = 0.61, P < 0.01). On subgroup analysis of patients who had a rise in blood ammonia levels after dialysis, there was a strong correlation with drop in mean arterial pressure (r = 0.88, P < 0.01). The nadir intradialytic systolic blood pressure trended lower in the hemodialysis patients who had a rise in blood ammonia compared to the patients who manifested a fall in blood ammonia (124 ± 8 vs. 136 ± 6 mmHg respectively, P = 0.27). Discussion: Fall in blood urea following hemodialysis in ESRD patients was paradoxically accompanied by a modest rise in blood ammonia levels in 43% of the patients studied, contrasting prior reported effects of hemodialysis on breath ammonia. In this subgroup of patients, changes in blood ammonia during hemodialysis correlated with rise in blood bicarbonate and fall in mean arterial blood pressure.