Much effort has been expended on determining which compound, hormone or metabolic condition causes the uremic syndrome. Byproducts of protein metabolism that can cause uremic symptoms, including loss of lean body mass, have been a focus of research but specific toxins have been difficult to identify. Evidence is provided that implicates metabolic acidosis as the prime signal initiating muscle wasting in uremia since it activates branched-chain ketoacid dehydrogenase and the ubiquitin proteasome pathway. These responses degrade the essential branched chain amino acids and protein in muscle, leading to loss of muscle mass. Correction of the metabolic acidosis with sodium bicarbonate supplements has significant therapeutic implications for uremic patients with even mild degrees of metabolic acidosis.