**6.2 Nutrition**

There is an imbalance between the increased protein requirement and the inadequate dietary food intake caused by HD, which results in skeletal muscle loss in CKD patients. Increased protein synthesis and anabolism from regular PE may help to slow the rate at which people lose lean body mass as they age. On non-HD days, however, As found in aged adults, and HD patients have a lower muscle protein synthesis response to diet. Furthermore, combining physical exercise with a high-protein diet has been shown to help decrease or even stop muscle loss. When used in conjunction with RE, intradialytic nutritional supplements improve both body composition and muscle mass. With PE, nutritional supplementation has significantly stronger protein anabolic effects when taken orally. Increased phosphorylation of mRNA translational signalling proteins due to RE and whey protein intake leads to enhanced protein synthesis in untrained individuals. In addition, ingestion of whey protein after RE activates the mTOR signalling pathway in a dose-dependent manner [63]. Supplementing PE with proper energy sources such as carbohydrates, protein, vitamins and iron will help keep muscle protein breakdown under control. Due to the energy loss and decreased digestive function

associated with dialysis, patients are advised to consume more protein (1.2 times) than the average person.
