In order to evaluate internal potassium balance in patients with end-stage renal disease (ESRD), epinephrine (0.015 μg/kg/min) was infused intravenously into normal control (N = 9) and ESRD subjects (N = 7) after a 26 hour fast. Hyperkalemia developed in ESRD patients after 16 hours of fasting, as compared with control subjects (P = 0.02). The hemodynamic response to epinephrine was similar in the two groups. During epinephrine infusion for one hour, the serum potassium decreased in normal subjects, from 4.3 ± 0.2 mEq/liter to 3.9 ± 0.1 mEq/liter, but did not change in ESRD patients (P = 0.005). Serum CO2 declined in ESRD, but not in control subjects, while glucose levels were not different in the two groups. Plasma aldosterone was significantly higher in fasting ESRD patients and failed to decrease during epinephrine infusion as compared to controls. Plasma insulin levels remained low in both groups even though serum glucose levels increased. These results demonstrate that hyperkalemia occurs during fasting in ESRD probably as the result of insulinopenia, and suggest that a diminished response to epinephrine may contribute to hyperkalemia.