The management of diabetes in patients with renal disease requires understanding of the multiple changes in carbohydrate metabolism that accompany renal failure. A decrease in insulin requirements may occur due to changes in insulin clearance or insulin metabolism. With the onset of uremia, a peripheral resistance to insulin action develops that often requires increased insulin administration, and this resistance can be expected to improve with adequate dialysis. Hypoglycemia may occur as a result of decreased gluconeogenesis, excessive insulin action, or decreased caloric intake. Thus, the treatment of diabetes in the settings of renal failures involves anticipation of changes in insulin sensitivity and insulin dosages. An overall management plan that coordinates diet, insulin, and dialysis where appropriate is most likely to yield optimum diabetic care.