INS and metabolic acidosis: Adynamic bone disease can be caused by metabolic acidosis, which can impact calcium balance and synthesis of vitamin D.[27] Earlier research discovered that metabolic acidosis has an impact on muscle as well, causing protein breakdown and disrupting the signaling of insulin/IGF-1 (Insulin-like Growth Factor 1), which ultimately results in a reduction of muscle strength.[28,29] The well-being of bones and muscles in individuals with CKD can be impacted by vitamin D insufficiency, as well as the presence of secondary hyperparathyroidism.