Hypovitaminosis D and Poor Nutritional Status are Independent Risk Factors of Insulin Resistance in Patients on Maintenance Hemodialysis

Author(s): Dr. Md Abdul Hakim, Prof. Dr. Md. Nazrul Islam, Dr. Md. Safayet Hossain Pramanik, Dr. Md. Saeed Hossain, Dr. Md. Tamim Aziz, Dr. Md. Shoriful Islam.

Background: Insulin resistance is one of the essential components of metabolic syndrome, is recognized in patients on maintenance hemodialysis, and is directly associated with increased cardiovascular mortality. Vitamin D deficiency is a risk factor for glucose intolerance, and 1,25 dihydroxy cholecalciferol regulates insulin secretion. Malnutrition is also a risk factor for insulin resistance and is associated with increased morbidity and mortality. Aims: To assess hypovitaminosis D, poor nutritional status, and independent risk factors of insulin resistance in patients on maintenance hemodialysis. Methods: This cross-sectional study was conducted in the Department of Nephrology, Dhaka Medical College, Dhaka, from May 2021 to October 2022. This study included one hundred twenty patients on maintenance hemodialysis according to inclusion and exclusion criteria. Statistical analyses of the results were obtained using window-based computer software devised with statistical packages for social sciences (SPSS-26). Results: It was observed that almost one-third (32.6%) of subjects belonging to age 41-50 years were insulin resistant, and 14(41.2%) were non-insulin resistant. The mean age was 50.36±12.03 years and 48.24±10.17 years in insulin and non-insulin resistance, respectively. More than half (53.5%) of subjects were male in insulin resistance, and 20(58.8%) in non-insulin resistance. According to the TST Z-score, 29(33.7%) and 2(5.9%) were malnourished in insulin-resistant presence and absence. According to the MAC Z-score malnourished was found 46(53.5%) insulin resistant were present, and 3(8.8%) were absent. According to the MAMC, Z-score malnourished was found in 37(43.0%) insulin-resistant patients and 3(8.8%) insulin-resistant patients. The difference between the two groups was statistically significant (p<0.05). Study subjects according to malnutrition score based on SGA, it was observed that more than two-thirds (67.4%) of subjects were mild to moderately malnourished in insulin resistant and 4(11.8%) in non-insulin resistant. The difference was statistically (p<0.05) significant between the two groups. About 78(90.7%) subjects had found Vitamin D deficiency (<20) levels in insulin resistant and 9 (26.47%) in non-insulin resistant subjects. Vitamin D deficiency had a 12.4 times risk of developing insulin resistance (OR=12.34; 95% CI=4.2-38.1). Eighteen (20.9%) of subjects had lower (<35g/l) serum albumin in insulin resistance and 2(5.9%) in non-insulin resistance. Low albumin had a 4.24 times risk of developing insulin resistance (OR=4.2;95% CI=0.9-28.2). The difference was statistically (p<0.05) significant between the two groups. Based on subjective global assessment, a significant positive correlation exists between insulin resistance and TST, MAC, MAMC, and malnutrition scores. There is a negative significant correlation between insulin resistance and vitamin D. Conclusion: Most of the patients on maintenance hemodialysis are Vitamin D deficient. Low Vitamin D levels and muscle mass will likely cause more insulin resistance in patients on maintenance hemodialysis.