Insulin resistance in chronic kidney disease: rational application of assessment methods and re-recognition of nutrition management

Abstract

Insulin resistance (IR) is a pathological state in which target tissues fail to respond normally to insulin. A compensatory rising in circulating insulin to maintain normal blood glucose levels results in hyperinsulinemia. Hyperinsulinemic euglycemic clamp is the gold standard for diagnosis of IR. Insulin sensitivity index estimated by fasting blood glucose or insulin and oral glucose tolerance test is commonly used in clinical practice. The combination of the two methods can better evaluate the IR of patients with chronic kidney disease (CKD). IR is a common alteration in CKD patients. The mechanism leading to CKD-IR mainly involves post-insulin receptor signal transduction disorder. The etiology of CKD-IR includes unhealthy diet, physical inactivity, metabolic acidosis, anemia, vitamin D deficiency, chronic inflammation, oxidative stress, and adipokine derangement, etc. Although there is still debate about the correlation between IR and renal and cardiovascular events, more and more clinical studies have confirmed that IR is an independent risk factor for occurrence or progression of CKD and cardiovascular complications. Interventions including lifestyle modifications, especially plant-based diets such as Mediterranean diet, dietary approaches to stop hypertension (DASH) diet, vegetarian diet, combined with aerobic exercise or resistance exercise, plus pharmacological strategies with metformin, pioglitazone, renin-angiotensin system (RAS) inhibitors, vitamin D, as well as adaptations of dialysis mode and optimization of membrane materials, may improve IR in patients with CKD. Key words: Insulin resistance; Chronic kidney disease; Nutritional therapy; Vegetarian diet