Atherosclerosis and cardiovascular complications are prevalent among patients undergoing chronic hemodialysis (HD). In this population, peripheral polymorphonuclear leukocytes (PMNLs) are primed, releasing pro-inflammatory mediators, such as elastase. Elastase is normally inhibited by a specific inhibitor, avoiding undesirable degradation of cellular and extracellular components. This study tested the hypothesis that in states of non-infectious inflammation, elastase is released by PMNLs and acts in an uncontrolled manner to inflict vascular damage. Blood was collected from HD patients and healthy controls (HC). PMNL intracellular and surface expression of elastase was determined by q-PCR, Western blotting and Flow cytometry. The elastase activity was evaluated using a fluorescent substrate. The levels of serum alpha1-anti trypsin (alpha1-AT), the natural elastase inhibitor, were determined by Western blot. Free active elastase was elevated in HD sera, while the levels of alpha1-AT, were decreased compared to HC. The levels of the intracellular elastase enzyme and its activity were lower in HD PMNLs despite similar expression levels of elastase mRNA. Elastase binding to PMNL cell surface was higher in HD compared to HC. The increased circulating levels of free active elastase released from primed HD PMNLs, together with the higher cell surface-bound enzyme and the lower levels of alpha1-AT result in the higher elastase activity in HD sera. This exacerbated elastase activity could lead to the endothelial dysfunction, as hypothesized. In addition, it suggests that free circulating elastase can serve as a new biomarker and therapeutic target to reduce inflammation and vascular complications in hemodialysis patients.