ammonia breath

[Sunny]

Yuck, I've had ammonia breath the last couple of weeks.
I am pre-dialysis with GFR about 18%. I will get my blood checked this week to see if there have been any changes.
But jeeeeez! What exactly causes ammonia breath in renal patients and what can I change in my diet to get rid of it.
I already assume it's from toxin build-up in low functioning kidneys. But I also know people on dialysis can get it.
Athletes can get it too if they work out too hard and don't replenish their diet properly.
It's really driving me crazy. I chew gum or eat breath mints or brush my teeth frequently. Do you know anything?

[flip]

a sip or two of good Kentucky bourbon works for me   

[monrein]

Ammonia  breath is a common side effect of uremia and really drove me nuts until I started dialysis.  I had a Gfr similar to yours Sunny and my creatinine was only 305.  The ammonia breath was so bad that it would cause gum to almost liquefy and would burn my tongue and throat.  I no longer have it since I started dialysis.

[pelagia]

My husband had this symptom as his kidney function declined.  And his urine had a fishy odor, which got stronger as his kidney function declined (sorry to be so graphic).  Ammonia (actually we excrete urea which is a compound that contains ammonia but is less toxic) results from the metabolism of protein.  Has your doctor recommended a low protein diet?

[monrein]

Good point about the protein.  Pre-dialysis I was put on 3 oz of protein a day. 

[Sunny]

Maybe I've been overdoing the protein. I try to stick to 21 grams or less a day but the past couple of weeks with the advent of summer I have been
attending various activities where protein is what's available. I'll try to be more vigilant and see if it helps. Flip, Kentucky Bourban just might do the trick!

[stauffenberg]

If you have healthy kidneys, then no matter how much protein you consume you will never have ammonia breath, which is a classic symptom of kidney disease and not correctable by diet.  I even found that that symptom persisted during my period on dialysis, since dialysis only replaces 10 to 14% of normal renal function.

[kellyt]

I've started with the amonia breath, as well.  It's not everyday and it's not bothersome yet.  I get labs drawn tomorrow.  We'll see how much closer I am to starting dialysis.

[lola]

Otto had the same problem but since starting D his breath is MUCH better THANK GOD

[pelagia]

If you have healthy kidneys, then no matter how much protein you consume you will never have ammonia breath, which is a classic symptom of kidney disease and not correctable by diet.  I even found that that symptom persisted during my period on dialysis, since dialysis only replaces 10 to 14% of normal renal function.

Some of the evidence I can find suggests a different conclusion can be reached:

At least one study has demonstrated that ammonia breath in dialysis patients is correlated with BUN (blood urea nitrogen) http://www.pnas.org/cgi/content/abstract/98/8/4617.   The authors found that higher BUN concentrations yield higher concentrations of ammonia in breath of dialysis patients. (Urea is converted to ammonia in saliva)

Blood urea nitrogen concentration in the blood is related to the metabolism of protein.  Isn't this why it is recommended that you do not eat protein before having a blood urea nitrogen test?:
http://www.webmd.com/a-to-z-guides/blood-urea-nitrogen. 

At this site: http://www.labtestsonline.org/understanding/analytes/bun/test.html they make the following statements: “BUN levels can increase with the amount of protein in your diet. High-protein diets may cause abnormally high BUN levels while very low-protein diets can cause an abnormally low BUN.” 

Interestingly, it looks as if the relationships between ammonia in the breath and BUN (and creatinine as well) in blood of dialysis patients have led to the development of new approach(es) to assessing the efficacy of dialysis in real time:

http://www.pranalytica.com/nephrolux.html
http://iospress.metapress.com/content/615m5861k2775428/

I also found both anecdotal and scientific evidence that athletes can have high ammonia concentrations in breath and sweat ammonia due to exercise:

http://www.ncbi.nlm.nih.gov/pubmed/10190765
http://au.messages.yahoo.com/lifestyle/general-fitness/132/

Have you come across papers that argue against these relationships?  I am surprised at how little there seems to be on the web.  I guess ammonia breath in and of itself is not an important area of study.

[monrein]

Well my ammonia breath has certainly disappeared since starting dialysis and my BUN has dramatically decreased.

[flip]

I never had ammonia breath. Maybe it was just all the booze and I never noticed.

[Sunny]

Very relevant information Pelagia.
This is the kind of info I found on the internet too.

[stauffenberg]

Elevated BUN in response to dietary protein is a perfectly normal condition of the healthy body and has nothing to do with renal disease or with the smell of ammonia in renal patients. The difference is that in renal failure, the by-products of protein metabolism cannot be eliminated by the kidneys in the urine, so instead they build up in the blood.  One of these by-products of protein metabolism is ammonia, and this explains why dialysis patients have ammonia breath.  If you put normal urine from a healthy person in a bottle and let it stand for a day, it will reek of ammonia; if you retain the components which normally go to form urine in your bloodstream instead because you don't have kidneys to clear them out, you will smell like ammonia.

Data show that an important influence on survival in renal patients is the adequacy of their nutrition, which is one reason why overweight patients on dialysis live longer than thin patients.  An essential element of adequate nutrition is sufficient protein in the diet, so while a protein-restricted diet will reduce the ammonia smell just by taking the source of protein metabolism by-products out of the bloodstream, it will do real medical harm for a purely aesthetic benefit.

[pelagia]

My comments about protein were made in the context of Sunny being pre-dialysis as she mentioned in her original message on this thread.  Adequate protein intake is very important for those on dialysis as mentioned by Stauffenberg.

[Sunny]

Good information from all. Thank you. Since I am pre-dialysis, the docs have always suggested a low protein diet.
I hadn't been vigilant enough lately. So after the ammonia breath issue, I cut way back on the protein and really paid attention to my
diet. Guess what, The ammonia breath went away!It amazes me how little changes in diet and fluid intake can create such differences for renal patients. I know it's important to maintain protein levels,though, for good health. My doctor at Stanford is of the opinion Americans eat way to much protein in general and that the body needs very little to function.
He provided a complicated ratio of protein grams to human weight to assist me in determining what amount I needed which was about 21 grams on average per day.
I recall a Web link from this forum once, but can't remember the site. Maybe somebody else here knows it.

[stauffenberg]

A maximum protein restriction diet would require 0.4 gms of protein per kilogram of body weight per day.  When calculating this, you have to consult a table of the protein content of the foods you are consuming, since even foods which in common parlance would count as 'pure protein,' such as meat, contain fewer grams of protein in them than they have grams of weight.

[Zach]

A maximum protein restriction diet would require 0.4 gms of protein per kilogram of body weight per day.

The National Kidney Foundation (U.S.A.) and its Kidney Disease Outcomes Quality Initiative (KDOQI), provides evidence-based clinical practice guidelines covering many issues affecting people on hemodialysis.

KDOQI recommends 1.2 grams of protein per kilogram of body weight per day.
http://www.kidney.org/professionals/kdoqi/guidelines_updates/nut_a15.html

 

[flip]

I've seen the predialysis diet listed at 0.6 g./kg. per day. My current diet is 1.3 g./kg./day.

[devon]

I'm curious... does it matter if it's animal protein or vegetable protein?  Do both types result in the "ammonia breath"?

Stauff, do you or anyone else, have some research on this?

Thanks.

-Devon

[stauffenberg]

Given the chemical nature of protein, any source, animal or vegetable, will break down to metabolic by-products containing ammonia.