The etiology of transient extreme insulin resistance in our case is likely to be multifactorial: for example, pathophysiological stress (DKA, MI, uremia, and CHF), early inappropriate switch of insulin from IV to subcutaneous while absorption was unpredictable due to edema or impaired peripheral circulation resulted in prolonged hyperglycemia and glucose toxicity and finally possible role of increased insulin clearance. Here, INS is linked to uremia.