<p>A 20-year-old male patient with H/o type1 DM and chronic kidney disease (GFR 18 ml/dl Was presented to the hospital with symptoms of fatigue, drowsiness and thirst (urinary Output:1000-2000 ml/d). He was under subcutaneous insulin therapy with poor blood Glucose control over the years. He had H/o severe proliferative retinopathy, and his BP was Maintained with diltiazem 120 mg twice daily. During admission, the patient&rsquo;s temperature (36.7&deg;C), BP (160/90 mm Hg), HR (105 Beats/min) and respiratory rate (16 breaths/min). The ECG showed sinus tachycardia with no Evidence of tibial oedema. The laboratory values were as follows:&nbsp;Hba1c 8%; urea 87 mg/dl; C peptide &amp;lt;0.3ng/ml. Creatinine 5.09 mg/dl; sodium 131 mmol/L; chloride 93 mmol/L; Glucose 830 mg/dl; potassium 5.2 mmol/L; serum osmolality 385 mosm/kg. After diagnosis, the patient was administered 4000 ccs of normal saline for the first 24 hours. Then, the patient was started with a loading dose of insulin (15 U) and continued with a&nbsp;Maintenance dose (2 U/h). After 10 hours, hyperglycemia was reduced to 230, and the serum&nbsp;sodium increased to 135 mmol/L.</p>