Diabetic ketoacidosis in the dialysis-dependent patient is a complex medical disorder and differs from the preserved renal function patients. However, it is seen very rarely but it has dramatic disturbance on balance of body water, solutes and acid-base balance. A-51-year-old hemodialysis patient with end-stage renal disease due to insulin dependent diabetes mellitus was admitted to our emergency clinic in a coma with respiratory distress and hypertension. He was hospitalized with a diagnosis of diabetic ketoacidosis. Insulin and esmolol infusion was started intravenously, and dialysis therapy was applied. He has improved 17 hours after initiation of treatment. We suggest that more attention should be given to water shifts between intracellular compartment and the extracellular compartment, change of tonicity and acid-base balance during the dialysis treatment.