Short-term exercise improves renal function in those with more moderate baseline chronic kidney disease. Thus, renal function appears to be responsive to enhanced physical fitness. Being a strong and modifiable risk factor, enhanced fitness should be considered a non-pharmacological adjunct in the management of diabetic kidney disease.

Introduction: Second generation antipsychotics (SGA) such as olanzapine are often used for psychotic disorders due to their efficacy and fewer neurological side effects. However, they have been associated with weight gain, prediabetes, diabetes ketoacidosis (DKA), myopathy and rarely rhabdomyolysis. These side effects were reported in individual cases. Our case had both DKA and rhabdomyolysis with chronic olanzapine use of 9 years. Case: A 36 year-old AAM with schizophrenia on olanzapine and risperidone, diet-controlled hyperlipidemia, obesity and prediabetes (HbA1c 6%,) admitted with fatigue, polyuria, polydipsia and confusion. He was diagnosed with DKA with HbA1c 13.7%, rhabdomyolysis (CK 13000 units/L) and acute kidney injury (peak creatinine 12, eGFR<10), requiring insulin infusion, dialysis and mechanical ventilation. Olanzapine was discontinued; his creatinine and glucose improved. His C-peptide was 4.28 ng/ml. Anti-GAD and islet cell antibodies were negative. He was discharged on glargine and risperidone. Two months after discharge, HbA1c was 5.8%, creatinine 1 (eGFR>60) and insulin was stopped. Discussion: This case highlights the importance of monitoring patients on SGA for metabolic complications. Olanzapine’s association with DKA is rare and with rhabdomyolysis is very rare. Several mechanisms for SGA-induced glucose intolerance exist, the most common being the antagonistic effect of olanzapine on serotonin 5HT2C and histamine (H1) receptors in the hypothalamus which leads to increased appetite and weight gain (our patient gained 40 lbs). Additionally, few reports on the association between olanzapine and rhabdomyolysis have been published. The mechanism remains unclear but may be due to drug-related myopathy secondary to high affinity for H1, 5-HT2A and D2 receptors. It is possible that the development of DKA predisposed our patient to developing rhabdomyolysis. Disclosure M. Akunjee: None. S.M. Gandhi: None. E. Nylen: None.

Although hypoglycemia is an expected occurrence with the use of insulin, this case demonstrates how complex it can be to uncover nontreatment causes of hypoglycemia. In this patient, the episodic and symptomatic hypoglycemia occurred between the same hours of the night and did not correlate with the prescribed medications. The authors excluded the more common causes of hypoglycemia and then considered the more obscure diagnostic scenarios.The authors detail the lack of evidence for autoimmune hypoglycemia (Hirata disease), perhaps the most likely among the obscure causes of hypoglycemia. More than 200 cases of antibody-associated hypoglycemia have been reported, with 90% of these being Japanese patients. Many of these cases were reported in patients with Graves disease on methimazole or other medications containing sulfhydryls.Presumed to be rare, factitious hypoglycemia is most often seen in people without diabetes who are healthcare workers, relatives of diabetes patients, and often women. People with diabetes manifesting this condition often have very erratic glycemic control. Even after eliminating other possibilities, factitious hypoglycemia can be difficult to prove and is often missed, leading to recurrent admissions and substantial healthcare costs. During episodes of hypoglycemia caused by sulfonylureas or meglitinides, laboratory results will show increases in insulin and C-peptide as well as detectable plasma concentrations of the medication. If the hypoglycemia is caused by exogenous insulin, however, laboratory results typically will show that the cosecreted C-peptide is low. The ratio of insulin to C-peptide also can be an informative measure in patients with type 1 diabetes. Factitious hypoglycemia is associated with a higher incidence of suicide, depression, and personality disorders, and it is important for physicians to be aware of the presentation and know how to distinguish it from other causes of hypoglycemia in a systematic manner. Thus, assessment must be done, as in this case, under monitored conditions. These patients often have to undergo behavioral treatment.