Hormone deficiencies (lower levels of insulin-like growth factor 1, vitamin D, and testosterone), inflammatory cytokine activation [upregulated expression of tumor necrosis factor-α (TNF- α) and interleukin-6 (IL-6)], and other metabolic disorders in cirrhosis also may lead to decreased skeletal muscle protein synthesis and increased autophagy (24). This evidence concerns the gene TNF and Other metabolic disease.