Relationship between Insulin Resistance and Inflamation Markers in Hemodialysis Patients

Current Technologies for Managing Type 1 Diabetes Mellitus and Their Impact on Quality of Life-A Narrative Review

Type 1 diabetes mellitus is a chronic autoimmune disease that affects millions of people and generates high healthcare costs due to frequent complications when inappropriately managed. Our paper aimed to review the latest technologies used in T1DM management for better glycemic control and their impact on daily life for people with diabetes. Continuous glucose monitoring systems provide a better understanding of daily glycemic variations for children and adults and can be easily used. These systems diminish diabetes distress and improve diabetes control by decreasing hypoglycemia. Continuous subcutaneous insulin infusions have proven their benefits in selected patients. There is a tendency to use more complex systems, such as hybrid closed-loop systems that can modulate insulin infusion based on glycemic readings and artificial intelligence-based algorithms. It can help people manage the burdens associated with T1DM management, such as fear of hypoglycemia, exercising, and long-term complications. The future is promising and aims to develop more complex ways of automated control of glycemic levels to diminish the distress of individuals living with diabetes.

Trends in insulin resistance: insights into mechanisms and therapeutic strategy

The centenary of insulin discovery represents an important opportunity to transform diabetes from a fatal diagnosis into a medically manageable chronic condition. Insulin is a key peptide hormone and mediates the systemic glucose metabolism in different tissues. Insulin resistance (IR) is a disordered biological response for insulin stimulation through the disruption of different molecular pathways in target tissues. Acquired conditions and genetic factors have been implicated in IR. Recent genetic and biochemical studies suggest that the dysregulated metabolic mediators released by adipose tissue including adipokines, cytokines, chemokines, excess lipids and toxic lipid metabolites promote IR in other tissues. IR is associated with several groups of abnormal syndromes that include obesity, diabetes, metabolic dysfunction-associated fatty liver disease (MAFLD), cardiovascular disease, polycystic ovary syndrome (PCOS), and other abnormalities. Although no medication is specifically approved to treat IR, we summarized the lifestyle changes and pharmacological medications that have been used as efficient intervention to improve insulin sensitivity. Ultimately, the systematic discussion of complex mechanism will help to identify potential new targets and treat the closely associated metabolic syndrome of IR.

Thyroid dysfunction and insulin resistance in end-stage renal disease patients before and 1 year after starting maintenance hemodialysis: A prospective multicenter study

BACKGROUND

Thyroid dysfunction and insulin resistance (IR) are common findings in patients with ESRD. We aimed to evaluate thyroid dysfunction and IR in ESRD before and after 1 year of starting hemodialysis (HD).

METHODS

This was a prospective study that recruited newly starting HD patients who fulfilled the inclusion criteria. Patients were evaluated for TSH, free T4, free T3, fasting insulin, fasting glucose, HOMA-IR, serum ferritin, and hs-CRP levels before starting their first dialysis session and after 1 year of regular HD.

RESULTS

Eighty-one patients have completed the 1-year follow-up period. After 1 year of regular HD, there were statistically significant increments of hs-CRP, serum ferritin, and TSH levels. On the other hand, fasting insulin level and HOMA-IR showed statistically significant increments after 1 year of starting HD. After 1 year of regular HD, TSH level showed a positive correlation with hs-CRP and serum ferritin level, while free T3 was negatively correlated with HOMA-IR. On the other hand, there was a significant positive correlation between HOMA-IR, hs-CRP, and serum ferritin levels, while HOMA-IR was negatively correlated with Kt/V.

CONCLUSIONS

This study suggests overlapping complex pathogenesis of thyroid dysfunction, chronic inflammation, and IR in chronic HD patients.

Cardiovascular diseases and metabolic abnormalities associated with obesity: What is the role of inflammatory responses? A systematic review

INTRODUCTION

Obesity is a chronic disease responsible for a high morbidity and mortality rate, with an increasing worldwide prevalence. Obesity is associated with immune responses characterized by chronic systemic inflammation. This article focuses on the mechanisms that explain the proposed link between obesity-associated diseases and inflammation. Also, it describes the role of inflammatory molecules in obesity-associated metabolic abnormalities.

METHODS

More than 200 articles were selected and consulted by an online English search using various electronic search databases. Predefined key-words for the pathogenesis of obesity-induced inflammation and associated diseases, as well as the role of various inflammatory molecules, were used.

RESULTS

We have summarized the data of the articles consulted in this research and we have found that obesity is associated with a low-grade inflammation resulting from the change of adipose tissue (AT). The AT produces a variety of inflammatory molecules called adipocytokines that are involved in the onset of systemic low-grade inflammation which is the link between obesity and associated-chronic abnormalities; such as insulin resistance, metabolic syndrome, cardiovascular disease (CVD), hypertension, diabetes, and some cancers. Also, we have searched all the inflammatory molecules involved in this pathogenesis and we have briefly described the role of 16 of them which are the most related to obesity-associated inflammation. The results have shown that there are inflammatory molecules that have a positive relationship with the pathogenesis of obesity-related diseases and others have a negative relationship with this pathogenesis.

CONCLUSION

Inflammation plays a crucial role in the development of various metabolic-abnormalities related to obesity. In this regard, the management of obesity may help reduce the risk of cardiovascular disease and other metabolic complications by inhibiting inflammatory mechanisms.

Evolving concepts in the pathogenesis of uraemic cardiomyopathy

The term uraemic cardiomyopathy refers to the cardiac abnormalities that are seen in patients with chronic kidney disease (CKD). Historically, this term was used to describe a severe cardiomyopathy that was associated with end-stage renal disease and characterized by severe functional abnormalities that could be reversed following renal transplantation. In a modern context, uraemic cardiomyopathy describes the clinical phenotype of cardiac disease that accompanies CKD and is perhaps best characterized as diastolic dysfunction seen in conjunction with left ventricular hypertrophy and fibrosis. A multitude of factors may contribute to the pathogenesis of uraemic cardiomyopathy, and current treatments only modestly improve outcomes. In this Review, we focus on evolving concepts regarding the roles of fibroblast growth factor 23 (FGF23), inflammation and systemic oxidant stress and their interactions with more established mechanisms such as pressure and volume overload resulting from hypertension and anaemia, respectively, activation of the renin-angiotensin and sympathetic nervous systems, activation of the transforming growth factor-β (TGFβ) pathway, abnormal mineral metabolism and increased levels of endogenous cardiotonic steroids.

Insulin Resistance and Cardiovascular Risks in Different Groups of Hemodialysis Patients: A Multicenter Study

BACKGROUND

To investigate the association between insulin resistance (IR) and cardiovascular disease (CVD) risks among hemodialysis patients.

METHODS

We conducted a cross-sectional study between 2013 and 2017, on 384 hemodialysis patients from seven hospital-based-dialysis centers. HOMA-IR is classified according to median value. The CVD risks were defined by the K/DOQI Guidelines. Logistic regression analysis was used.

RESULTS

Patients' age was 60.9 ± 11.8, 58.1% men, and 40.3% overweight/obese. The median of HOMA-IR was 5.4, 82.8% high systolic blood pressure, and 85.7% hyperhomocysteinemia. In multivariate analysis, IR was significantly associated with higher odds of low high-density lipoprotein cholesterol, high triglyceride, and impaired fasting glucose in groups of normal weight, overweight/obese, nondiabetes, diabetes, and overall sample. IR linked with elevated high-sensitive C-reactive protein in normal weight patients (odd ratio, OR=2.21, 95% confidence interval, 1.16-4.22, p < .05), with hypoalbuminemia in normal weight patients (OR=8.31, 95% CI, 2.35-29.37, p < .01), in nondiabetes patients (OR=6.59, 95% CI, 1.81-23.95, p < .01), and overall sample (OR=3.07, 1.51-6.23, p < .01).

CONCLUSIONS

The level of IR and prevalence of CVD risks were high in hemodialysis patients. IR was independently associated with CVD risks.

Chronic Kidney Disease-Induced Insulin Resistance: Current State of the Field

PURPOSE OF REVIEW

Insulin resistance is an early complication of chronic kidney disease (CKD) associated with worsening cardiovascular outcomes. This review will evaluate mechanisms responsible for CKD-induced insulin resistance and therapies currently available.

RECENT FINDINGS

Recent mechanisms have been identified including SIRPα and specific E3 ubiquitin ligases causing insulin resistance in CKD. The hallmark finding in these mechanisms is degradation of the insulin receptor substrate 1 (IRS1) which impairs intracellular insulin signaling and ultimately metabolism. The mechanisms responsible for insulin resistance in CKD include inflammation, oxidative stress, elevations in aldosterone, angiotensin II, uremic toxins, and metabolic acidosis. Potential treatments currently available for CKD-induced insulin resistance include lifestyle modification and metformin. Potential future treatments may include glucagon-like peptide agonists, SGLT2 inhibitors, and thiazolidinediones. Investigations into molecular mechanisms responsible for insulin resistance in CKD may provide new therapeutic targets while current therapies may prevent the catabolic sequelae of CKD and ameliorate its cardiovascular consequences.

Insulin Resistance Is Associated with Interleukin 1β (IL-1β) in Non-Diabetic Hemodialysis Patients

Background

Insulin resistance (IR) and inflammation are associated with increased risk of complications in chronic kidney disease (CKD) patients. However, the relationship between IR and the important proinflammatory interleukin-1β (IL-1β) is unclear in CKD patients.

Material/Methods

We conducted a cross-sectional study including 79 non-diabetic patients who received hemodialysis after the exclusion process. Homeostasis model assessment (HOMA-IR) and leptin adiponectin ratio (LAR) were used to evaluate IR. Inflammation was assessed through C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and IL-1β evaluation. We tested associations of IR with IL-1β using logistic analysis and linear regression.

Results

Patients were divided into a HOMA-IR-positive group and a HOMA-IR-negative group. Although there were no differences between the 2 groups in terms of etiological causes, age, sex, BMI, triglyceride, cholesterol, ferritin, uric acid, and inflammatory indicators such as CRP, we found that IL-6, TNF-α, and IL-1β were significantly increased in the HOMA-IR-positive group compared with the HOMA-IR-negative group. Moreover, IL-1β contributed to HOMA-IR positivity and was positively correlated with LAR after adjusting for possible confounding factors.

Conclusions

Insulin resistance correlates positively with IL-1β among non-diabetic hemodialysis patients, which suggests that IL-1β may be involved in the pathogenesis of IR in this setting.

Insulin resistance in chronic kidney disease: a systematic review

Insulin resistance (IR) is an early metabolic alteration in chronic kidney disease (CKD) patients, being apparent when the glomerular filtration rate is still within the normal range and becoming almost universal in those who reach the end stage of kidney failure. The skeletal muscle represents the primary site of IR in CKD, and alterations at sites beyond the insulin receptor are recognized as the main defect underlying IR in this condition. Estimates of IR based on fasting insulin concentration are easier and faster but may not be adequate in patients with CKD because renal insufficiency reduces insulin catabolism. The hyperinsulinemic euglycemic clamp is the gold standard for the assessment of insulin sensitivity because this technique allows a direct measure of skeletal muscle sensitivity to insulin. The etiology of IR in CKD is multifactorial in nature and may be secondary to disturbances that are prominent in renal diseases, including physical inactivity, chronic inflammation, oxidative stress, vitamin D deficiency, metabolic acidosis, anemia, adipokine derangement, and altered gut microbiome. IR contributes to the progression of renal disease by worsening renal hemodynamics by various mechanisms, including activation of the sympathetic nervous system, sodium retention, and downregulation of the natriuretic peptide system. IR has been solidly associated with intermediate mechanisms leading to cardiovascular (CV) disease in CKD including left ventricular hypertrophy, vascular dysfunction, and atherosclerosis. However, it remains unclear whether IR is an independent predictor of mortality and CV complications in CKD. Because IR is a modifiable risk factor and its reduction may lower CV morbidity and mortality, unveiling the molecular mechanisms responsible for the pathogenesis of CKD-related insulin resistance is of importance for the identification of novel therapeutic targets aimed at reducing the high CV risk of this condition.

Healthy effect of different proportions of marine ω-3 PUFAs EPA and DHA supplementation in Wistar rats: Lipidomic biomarkers of oxidative stress and inflammation

Dietary intervention with ω-3 marine fatty acids may potentially modulate inflammation and oxidative stress markers related with CVD, metabolic syndrome and cancer. The aim of this study was to evaluate whether different proportions of ω-3 EPA and DHA intake provoke a modulation of the production of lipid mediators and then, an influence on different indexes of inflammation and oxidative stress in a controlled dietary animal experiment using Wistar rats. For such scope, a lipidomic SPE-LC-ESI-MS/MS approach previously developed was applied to determine lipid mediators profile in plasma samples. The effect of ω-3 fatty acids associated to different ratios EPA:DHA was compared with the effect exerted by ω-3 ALA supplementation from linseed oil and ω-6 LA from soybean oil. CRP showed a tendency to greater inflammatory status in all ω-3-fed animals. Interestingly, ratios 1:1 and 2:1 EPA:DHA evidenced a noteworthy healthy effect generating a less oxidative environment and modulating LOX and COX activities toward a decrease in the production of proinflammatory ARA eicosanoids and oxidative stress biomarkers from EPA and DHA. In addition, the ability of 1:1 and 2:1 fish oil diets to reduce lipid mediator levels was in concurrence with the protective effect exerted by decreasing inflammatory markers as ω-6/ω-3 ratio in plasma and membranes. It was also highlighted the effect of a higher DHA amount in the diet reducing the healthy benefits described in terms of inflammation and oxidative stress. Results support the antiinflammatory and antioxidative role of fish oils and, particularly, the effect of adequate proportions EPA:DHA.

Visceral adipose tissue is associated with insulin resistance in hemodialyzed patients

BACKGROUND

It has not been definitively established which factors affect insulin resistance (IR) and whether dialysis decreases IR. The aim of this study was to investigate factors that may have an influence on homeostasis model assessment (HOMA-IR) in hemodialyzed patients (HDpts) and to compare IR between HDpts and healthy subjects.

MATERIAL AND METHODS

We examined 33 HDpts and paired 33 subjects of the control group, matched for sex, age, and BMI. We analyzed concentrations of insulin, glucose, leptin, resistin, and total and high-molecular-weight adiponectin (HMWad) in serum. Using computed tomography in HDpts, we evaluated visceral adipose tissue (VAT), concentrations of visfatin, CRP, and IL-6.

RESULTS

HOMA-IR (median, 1.3 vs. 1.4, P=0.19), insulin (median 6.8 vs. 6.0 µIU/mL, P=0.7), glucose (79 mg/dL vs. 93 mg/dL, P=0.001). IR in HDpts is dependent on VAT (r=0.36, P=0.04) and this relationship is stronger than the relationship of BMI and IR (r=0.3, P=0.1). In HDpts we found higher concentrations of leptin (P=0.001) and resistin (P<0.001), with no relation to IR. HMWad and its percentage in relation to total adiponectin are higher in HDpts (P=0.03 and P<0.001, respectively).

CONCLUSIONS

HOMA-IR in HDpts does not differ from the control group. In HDpts it depends on the quantity of VAT and this relationship is stronger than with BMI. In HDpts leptin and resistin do not influence IR. HMWad and its percentage in total adiponectin are significantly higher in HDpts.

A pilot study of active vitamin D administration and insulin resistance in African American patients undergoing chronic hemodialysis

OBJECTIVE

Insulin resistance (IR) is associated with increased cardiovascular risk in multiple patient populations, including those undergoing chronic hemodialysis (CHD). Active vitamin D deficiency has been proposed to play a role in the extent of IR observed in patients with CHD. We postulated that administration of paracalcitol, an active vitamin D medication, influences IR in patients with CHD.

DESIGN AND METHODS

This was a pilot randomized controlled trial. Ten prevalent CHD patients receiving a stable dose of paracalcitol were recruited. Paracalcitol was withheld for 8 weeks in all patients (phase I). Parathyroid hormone levels were managed with the calcium-sensing receptor agonist cinacalcet. At week 8, patients were randomized to continue cinacalcet or to restart paracalcitol for 8 weeks (phase II). The primary outcome was the change in IR measured by the glucose disposal rate (GDR) using hyperinsulinemic euglycemic clamp (HEGC) method. Secondary outcomes included changes in IR between groups in indirect indices of IR, biomarkers of inflammation, and adipokine levels.

RESULTS

The mean age was 49 years (range, 46-57 years) and 40% of patients were women. There was no detectable change in the GDR at the end of phase I (P = .7) when compared with baseline values. There was also no statistically significant difference in GDR between groups at the end of phase II (P = .9). No changes were observed in indirect indices of IR, adipokine levels, or biomarkers of inflammation in either phase.

CONCLUSION

The results of this pilot study suggest that withdrawal of paracalcitol over 8 to 16 weeks and replacement for 8 weeks after withdrawal does not influence IR measured by HEGC in patients receiving CHD.

Early sympathetic activation in the initial clinical stages of chronic renal failure

Direct and indirect indices of neuroadrenergic function have shown that end-stage renal disease is characterized by a marked sympathetic overdrive. It is unknown, however, whether this phenomenon represents a peculiar feature of end-stage renal disease or whether it is also detectable in the early clinical phases of the disease. The study has been performed in 73 hypertensive patients, of which there were 42 (age: 60.7±1.8 years, mean±SEM) with a stable moderate chronic renal failure (mean estimated glomerular filtration rate: 40.7 mL/min per 1.73 m2, MDRD formula) and 31 age-matched controls with a preserved renal function. Measurements included anthropometric variables, sphygmomanometric and beat-to-beat blood pressure, heart rate (ECG), venous plasma norepinephrine (high-performance liquid chromatography), and efferent postganglionic muscle sympathetic nerve activity (microneurography, peroneal nerve). For similar anthropometric and hemodynamic values, renal failure patients displayed muscle sympathetic nerve activity values significantly and markedly greater than controls (60.0±2.1 versus 45.7±2.0 bursts per 100 heartbeats; P<0.001). Muscle sympathetic nerve activity showed a progressive and significant increase from the first to the fourth quartile of the estimated glomerular filtration rate values (first: 41.0±2.7; second: 51.9±1.7; third: 59.8±3.0; fourth: 61.9±3.3 bursts per 100 heartbeats), the statistical significance (P<0.05) between groups being maintained after adjustment for confounders. In the population as a whole, muscle sympathetic nerve activity was significantly and inversely correlated with the estimated glomerular filtration rate (r=-0.59; P<0.0001). Thus, adrenergic activation is a phenomenon not confined to advanced renal failure but already detectable in the initial phases of the disease. The sympathetic overdrive parallels the severity of the renal failure, state and, thus, it might participate, in conjunction with other factors, at the disease progression.