A 47-year-old man with long-standing type 2 diabetes on treatment with metformin (850 mg/8 h) and glimepiride (4 mg/day), an active smoker and regular drinker. He had had several episodes of acute non-lithiasic pancreatitis. A week before admission, he had a syncopal episode while working in the fields. Subsequently, he presented intense asthenia, hypoorexia and general malaise with orthostatism. He attended the health centre with a blood pressure of 70/35 mmHg and capillary glycaemia of 20 mg/dl, for which glucagon was administered i.v. In the emergency department, hypotension persisted, with signs of extracellular volume depletion and tachypnoea. Blood tests showed plasma Cr 10.3 mg/dl, glycaemia 287 mg/dl and lactic acid 20 mmol/l. Arterial blood gas revealed a pH of 6.87 with bicarbonate of 2.2 mEq/l. Orotracheal intubation was performed and he was admitted to the ICU with assisted ventilation and inotropic administration. Subsequently, haemodialysis was performed for four hours followed by continuous venovenous haemofiltration with analytical improvement. At discharge he had a Cr of 1.20 mg/dl, pH of 7.46 and bicarbonate of 24.6 mEq/l.