. Protein intake during hemodialysis maintains a positive whole body protein balance in chronic hemodialysis patients. Am J Physiol Endocrinol Metab 284: E954-E965, 2003. First published January 21, 2003 10.1152/ajpendo.00264.2002.-Protein energy malnutrition is present in 18 to 56% of hemodialysis patients. Because hemodialysis has been regarded as a catabolic event, we studied whether consumption of a protein-and energyenriched meal improves the whole body protein balance during dialysis in chronic hemodialysis (CHD) patients. Patients were studied on a single day between dialysis (HDϪ protocol) in the morning while fasting and in the afternoon while consuming six small test meals. Patients were also studied during two separate dialysis sessions (HDϩ protocol). Patients were fasted during one and consumed the meals during the other. Whole body protein metabolism was studied by primed constant infusion of L-[1-13 C]valine. During HDϪ, feeding changed the negative whole body protein balance observed during fasting to a positive protein balance. Dialysis deepened the negative balance during fasting, whereas feeding during dialysis induced a positive balance comparable to the HDϪ protocol while feeding. Plasma valine concentrations during the studies were correlated with whole body protein synthesis and inversely correlated with whole body protein breakdown. We conclude that the consumption of a protein-and energy-enriched meal by CHD patients while dialyzing can strongly improve whole body protein balance, probably because of the increased amino acid concentrations in blood. protein turnover; stable isotope; valine SIGNS OF PROTEIN ENERGY MALNUTRITION occur frequently in patients with chronic renal failure (17, 19). Protein energy malnutrition has been shown to be a major risk factor for increased morbidity and mortality in the chronic hemodialysis (CHD) patient (2, 17). Multiple factors predispose CHD patients to protein energy malnutrition, e.g., low caloric intake, low protein intake, and the hemodialysis procedure itself. Particularly, losses of amino acids or abnormal protein metabolism during hemodialysis might contribute to the observed protein energy malnutrition. Studies examining the role of CHD itself on protein metabolism are limited (22). Several lines of evidence indicate that the CHD procedure can result in a negative whole body protein balance. Nitrogen balance has been shown to be more negative on a dialysis day compared with a nondialysis day regardless of daily protein intake (5, 23). Lim et al. (22) studied whole body protein metabolism by applying the [ 13 C]leucine isotope dilution technique in fasting CHD patients during hemodialysis. They observed a reduction in whole body protein synthesis compared with the predialysis period, and this resulted in a doubling of the negative protein balance already present in fasting CHD patients. Furthermore, hemodialysis stimulates muscle protein losses compared with the predialysis period in fasting CHD patients (18).In apparently healthy subjects, the...