Background An accelerated muscle wasting was the pivotal factor for protein-energy wasting in end stage renal disease.However,very few researches have examined the skeletal muscle quantity and quality in clinical patients.This study investigated the muscle morphologic changes by magnetic resonance imaging (MRI) and analyzed the related factors in hemodialysis patients.Methods Fifty-eight patients receiving maintenance hemodialysis (HD) were investigated and 28 healthy adults with gender and age matched were used as controls (Control).Anthropometry,cytokine factors,and laboratory data were measured.The muscle and intermuscular adipose tissues (IMAT) were analyzed via a Thigh MRI.The bicep samples were observed after HE staining.Homeostatic model assessment of insulin resistance (HOMA-IR) was measured and their association with muscle wasting was analyzed.Results HD patients tended to have a lower protein diet,anthropometry data,and serum albumin,but the C reactive protein and interleukin-6 increased significantly.The MRI showed that HD patients had less muscle mass and a lower muscle/total ratio,but the fat/muscle and IMAT was higher when compared to the Control group.The muscle fiber showed atrophy and fat accumulation in the biceps samples come from the HD patients.Moreover,we found that the HD patients presented with a high level of plasma fasting insulin and increased HOMA-IR which negatively correlated with the muscle/total ratio,but positively with the fat/muscle ratio.Conclusions Muscle wasting presented early before an obvious malnutrition condition emerged in HD patients.The main morphological change was muscle atrophy along with intermuscular lipid accumulation.Insulin resistance was associated with muscle wasting in dialysis patients.