Q: At what level of decreased Glomerular filtration rate (GFR), insulin resistance (IR) may occur? 

Answer:  around 50 or less

Clinical relevance: IR is common (but may go unnoticed due to its sub-clinical manifestations) in patients with mild-to-moderate CKD (Chronic Kidney Disease). Consequently, IR is an independent predictor of cardiovascular mortality in ESRD, therefore, IR may be an important therapeutic target for reduction of cardiovascular mortality in patients with CKD.

Treatment: Thiazolidinediones (TZDs) are a class of oral diabetic medications that increase insulin sensitivity in peripheral tissue. Also, proper nutritional supplementation, prevention of dyslipidemia, vitamin D deficiency and anemia  improves insulin sensitivity among the CKD population.

References:

S. Kobayashi, K. Maesato, H. Moriya, T. Ohtake, and T. Ikeda, “Insulin resistance in patients with chronic kidney disease,” American Journal of Kidney Diseases, vol. 45, no. 2, pp. 275–280, 2005.

K. Shinohara, T. Shoji, M. Emoto et al., “Insulin resistance as an independent predictor of cardiovascular mortality in patients with end-stage renal disease,” Journal of the American Society of Nephrology, vol. 13, no. 7, pp. 1894–1900, 2002.

S. M. Brunelli, R. Thadhani, T. A. Ikizler, and H. I. Feldman, “Thiazolidinedione use is associated with better survival in hemodialysis patients with non-insulin dependent diabetes,” Kidney International, vol. 75, no. 9, pp. 961–968, 2009.