Figure 1 Circadian changes in energy metabolism and immune responses in CKD Figure 1 | Circadian changes in energy metabolism and immune responses in CKD.

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Figure 1 Circadian changes in energy metabolism and immune responses in CKD Figure 1 | Circadian changes in energy metabolism and immune responses in CKD. Metabolic and endocrine responses can be promoted or inhibited in patients with chronic kidney disease (CKD). During the circadian cycle in these patients sympathetic activity is markedly increased, whereas the hypothalamic–pituitary axis is dysfunctional. Cortisol and glucagon levels are elevated mainly as a consequence of reduced renal clearance of these hormones and circadian changes in cortisol levels are abolished in this disease. Insulin levels are also high and insulin resistance is a hallmark of CKD. Similarly levels of growth hormone are substantially raised and this change is accompanied by marked resistance to its metabolic effects. Melatonin levels are depressed, particularly during the night, prolactin levels are elevated and the 24 h rhythmicity of these hormones is disrupted in advanced CKD. Gluconeogenesis is enhanced, whereas glycogenolysis shows an opposite response and these alterations in glucose metabolism are accompanied by reduced β-fatty acid oxidation and increased lipogenesis and lipolysis. Figure adapted with permission from John Wiley and Sons © Straub, R. H. et al., J. Intern. Med. 267, 543–560, (2010). Figure adapted with permission from John Wiley and Sons © Straub, R. H. et al., J. Intern. Med. 267, 543–560, (2010) Zoccali, C. et al. (2017) The systemic nature of CKD Nat. Rev. Nephrol. doi:10.1038/nrneph.2017.52