INS and chronic kidney disease: Workeneh and Mitch (2010) reported a possible mechanism for the link between the loss of muscle mass and CKD as follows: inflammation, metabolic acidosis, and angiotensin II cause defects in insulin/ insulin-like growth factor 1 (IGF-1)-activated intracellular signaling, which aggravates muscle protein degradation by the ubiquitin proteasome system and caspase-3 [27].