FIGURE 1:

The effects of hemodialysis coupled with inadequate nutrient intake on muscle loss. Dialysis contributes to underlying factors that result in protein energy wasting. The dialysis process induces the activation of defense mechanisms, and the body reacts by increasing acute phase protein synthesis and initiating the inflammation cascade. In this setting, chronic undernutrition and amino acid (AA) losses into dialysate lead to low availability of circulating AA for protein synthesis. The body, in turn, increases muscle protein catabolism to promote AA release as a substrate for acute-phase proteins; this muscle catabolism activates cytokine production in the muscle, which tends to perpetuate this process in a vicious cycle.