Diabetic kidney disease

Last updated: July 5, 2023

CME information and disclosurestoggle arrow icon

To see contributor disclosures related to this article, hover over this reference: [1]

Physicians may earn CME/MOC credit by searching for an answer to a clinical question on our platform, reading content in this article that addresses that question, and completing an evaluation in which they report the question and the impact of what has been learned on clinical practice.

AMBOSS designates this Internet point-of-care activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

For answers to questions about AMBOSS CME, including how to redeem CME/MOC credit, see "Tips and Links" at the bottom of this article.

Summarytoggle arrow icon

Diabetic kidney disease is a chronic kidney disease (CKD) caused by chronic hyperglycemia and is a major cause of end-stage renal disease (ESRD). In type 1 diabetes mellitus (T1DM), diabetic kidney disease usually occurs 10 years after diagnosis, whereas it can occur at the time of onset of type 2 diabetes mellitus (T2DM). Patients are usually asymptomatic, and diagnosis is based on the presence of albuminuria and/or reduced eGFR and the exclusion of other causes of CKD. Management includes optimization of glycemic control through lifestyle modifications and pharmacotherapy, and management of CKD, including management of hypertension and ASCVD risk factors as needed.

Epidemiologytoggle arrow icon

  • Affects up to 40% of adults with diabetes and is a major cause of ESRD [2]
  • Onset varies depending on the type of diabetes: [2]
    • Type 1 DM: Diabetic kidney disease usually occurs approx. 10 years after diagnosis.
    • Type 2 DM: may be present at the time of diagnosis

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Pathophysiologytoggle arrow icon

Chronic hyperglycemiaglycation (also called non-enzymatic glycosylation or NEG) of the basement membrane (protein glycation) → increased permeability and thickening of the basement membrane and stiffening of the efferent arteriole → hyperfiltration (increase in GFR) → increase in intraglomerular pressure; progressive glomerular hypertrophy, increase in renal size, and glomerular scarring (glomerulosclerosis) → worsening of filtration capacity [3]

Pathologytoggle arrow icon

Three major histological changes can be seen on light microscopy. [4][5]

Clinical featurestoggle arrow icon

Diagnosticstoggle arrow icon

Approach [2][6]

Laboratory studies [2][6]

Repeat laboratory studies after 3–6 months to confirm persistent albuminuria and/or reduced eGFR. [6]

Microalbuminuria may progress to macroalbuminuria. [8]

Managementtoggle arrow icon

Approach [2][6][9]

Diabetic kidney disease usually occurs together with retinopathy in T1DM. [6][10]

Glycemic control and antihypertensive treatment can delay the progression of diabetic kidney disease. [2]

Management of underlying risk factors

Modifications to antihyperglycemic treatment in diabetic kidney disease [2][6][9]

  • Glycemic targets [9]
    • Measure HbA1c at least twice yearly. [6]
    • An HbA1c of < 6.5–8% is generally recommended. [6]
    • HbA1c may not be an accurate method of glucose monitoring in patients with an eGFR < 30 mL/min/1.73 m2; consider continuous glucose monitoring.
  • Pharmacotherapy [6]
Treatment of T2DM in patients with CKD [6]
Recommended pharmacotherapy
eGFR ≥ 30 mL/min/1.73 m2
eGFR < 30 mL/min/1.73 m2
Patients with a kidney transplant
  • Paucity of evidence to guide practice
  • Follow guidelines for treatment according to eGFR.
  • SGLT2 inhibitors may theoretically increase the risk of severe infection in immunocompromised patients.

SGLT-2 inhibitors improve renal and cardiovascular outcomes in patients with T2DM and CKD; their use is even recommended for patients who meet HbA1c targets. [6]

Adjust the dosing of antihyperglycemic medications in patients with reduced eGFR as needed. Metformin is contraindicated in patients with an eGFR < 30 mL/min/1.73 m2. [6]

Management of ASCVD risk factors for patients with diabetic kidney disease [6]

Patients should undergo management of ASCVD risk factors in CKD with the following modifications for hypertension management: [2][6]

RAS inhibitors should not be prescribed to normotensive patients as trials have not shown a renoprotective effect in this cohort. [10]

Nonsteroidal mineralocorticoid receptor antagonists are associated with improved cardiovascular and renal outcomes. [6]

ACE inhibitors and angiotensin receptor blockers are potential teratogens and should not be used in pregnant patients. Avoid use in women of childbearing age who do not use contraception. [11][12]

Management of CKD in patients with diabetes [2][6][9]

Follow-up for diabetic kidney disease

Preventiontoggle arrow icon

RAS inhibitors slow the progression of diabetic kidney disease but do not prevent its development. [2]

Screening for diabetic kidney disease [2][6]

Educate patients on the importance of regular screening; fewer than half of patients with diabetes have been screened for albuminuria in the past year. [6]

Referencestoggle arrow icon

  1. Nuha A. ElSayed, Grazia Aleppo, Vanita R. Aroda, Raveendhara R. Bannuru, Florence M. Brown, et al.. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2023. Diabetes Care. 2022; 46 (Supplement_1): p.S191-S202.doi: 10.2337/dc23-s011 . | Open in Read by QxMD
  2. Tervaert TWC, Mooyaart AL, Amann K, et al. Pathologic Classification of Diabetic Nephropathy. Journal of the American Society of Nephrology. 2010; 21 (4): p.556-563.doi: 10.1681/asn.2010010010 . | Open in Read by QxMD
  3. Alsaad KO, Herzenberg AM. Distinguishing diabetic nephropathy from other causes of glomerulosclerosis: an update. J Clin Pathol. 2007; 60 (1): p.18-26.doi: 10.1136/jcp.2005.035592 . | Open in Read by QxMD
  4. Alicic RZ, Rooney MT, Tuttle KR. Diabetic Kidney Disease. Clin J Am Soc Nephrol. 2017; 12 (12): p.2032-2045.doi: 10.2215/cjn.11491116 . | Open in Read by QxMD
  5. de Boer IH, Khunti K, Sadusky T, et al. Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care. 2022.doi: 10.2337/dci22-0027 . | Open in Read by QxMD
  6. Khitan ZJ, Glassock RJ. Foamy Urine. Clin J Am Soc Nephrol. 2019; 14 (11): p.1664-1666.doi: 10.2215/cjn.06840619 . | Open in Read by QxMD
  7. Amin R, Widmer B, Prevost AT, et al. Risk of microalbuminuria and progression to macroalbuminuria in a cohort with childhood onset type 1 diabetes: prospective observational study. BMJ. 2008; 336 (7646): p.697-701.doi: 10.1136/ . | Open in Read by QxMD
  8. Navaneethan SD, Zoungas S, Caramori ML, et al. Diabetes Management in Chronic Kidney Disease: Synopsis of the KDIGO 2022 Clinical Practice Guideline Update. Ann Intern Med. 2023.doi: 10.7326/m22-2904 . | Open in Read by QxMD
  9. American Diabetes Association Professional Practice Committee. Chronic Kidney Disease and Risk Management: Standards of Medical Care in Diabetes 2022. Diabetes Care. 2021; 45 (Supplement_1): p.S175-S184.doi: 10.2337/dc22-s011 . | Open in Read by QxMD
  10. Nuha A. ElSayed, Grazia Aleppo, Vanita R. Aroda, Raveendhara R. Bannuru, Florence M. Brown, et al.. 15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes—2023. Diabetes Care. 2022; 46 (Supplement_1): p.S254-S266.doi: 10.2337/dc23-s015 . | Open in Read by QxMD
  11. Nuha A. ElSayed, Grazia Aleppo, Vanita R. Aroda, Raveendhara R. Bannuru, Florence M. Brown, et al.. Children and Adolescents: Standards of Care in Diabetes—2023. Diabetes Care. 2022; 46 (Supplement_1): p.S230-S253.doi: 10.2337/dc23-s014 . | Open in Read by QxMD
  12. $Contributor Disclosures - Diabetic kidney disease. All of the relevant financial relationships listed for the following individuals have been mitigated: Alexandra Willis (copyeditor, is an independent contractor for OPEN Health Communications); Jan Schlebes (medical editor, is a shareholder in Fresenius SE & Co KGaA). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer