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In dialysis patients who develop cramps as a result of carnitine deficiency, it is said that muscle symptoms occur due to increased burden on each cell because of insufficient energy production in the muscle cells compared to healthy individuals by shifting of the energy sources from fatty acids to sugars and proteins, which in turn are caused by decreased blood and muscle carnitine levels

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Furthermore, certain amino acid-derived metabolites, such as -ketoglutarate (-KG), acetyl-CoA, NAD + , and S-adenosylmethionine (SAM), modulate gene expression through epigenetic mechanisms (50)

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