Several factors contribute to an increased risk of hypoglycemia in these patients, including impaired kidney function in gluconeogenesis, reduced clearance of insulin by the kidneys, compromised insulin degradation due to uremia, enhanced glucose uptake by erythrocytes during HD, impaired responses of counterregulatory hormones (such as cortisol and growth hormone), nutritional deprivation, and variable exposure to oral antihyperglycemic agents and exogenous insulin (20). This evidence concerns the gene INS and uremia.