To the Editor: The article of Walker et al. (N Engl J Med 291:168–171, 1974) is interesting, but prompts these comments. In our own four patients with cirrhosis, ammonia levels fell in none and rose in one after oral glucose loading. 1, 2 Ammonia may be liberated from 3 as well as removed by 4 muscle. Exercise liberates ammonia, and the rise of peripheral venous ammonia is greater in patients with cirrhosis than in controls. 5 Therefore, we have to know whether or not the patients of Walker et al. were recumbent and at rest before and during the nine hours of study. As has.
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