GH1 and metabolic acidosis: In CKD, PEW pathogenic mechanisms, including systemic inflammation, triggered by the accumulation of uremic toxins, immune cell defects, gut dysbiosis and dialysis-related factors, metabolic acidosis, disrupted growth hormone (GH)–IGF-1 axis, insulin resistance, anemia, mineral bone disorders and activation of the renin–angiotensin system have been implicated in the muscle mass and strength wasting process (Figure 1) [56].