diabetic renal disease

Last edited 06/2021 and last reviewed 06/2022

Diabetic nephropathy is an important cause of morbidity and death amongst diabetics.

  • 30% **of patients with type 1 diabetes go on to develop chronic renal failure
  • 25% ***of patients with type 2 diabetes develop CRF though this level may be 50% in certain ethnic groups

The incidence of diabetic nephropathy increases with age. It almost never occurs in childhood.

Different forms of nephropathy:

  • pyelonephritis - which may show papillary necrosis
  • glomerulonephritis:
    • Kimmelstiel-Wilson - eosinophilic nodules in the glomerular tuft
    • proliferative
  • atherosclerosis and hypertensive changes


  • microscopic albuminuria is a sensitive early predictor of subsequent overt renal disease
  • proteinuria is usually the earliest clinical sign of nephropathy.
  • hypertension is not a feature of early nephropathy. Hypertension is a feature associated with a more rapid progression of diabetic nephropathy.
  • nodular sclerosis (Kimmelstiel-Wilson), although the most specific form of diabetic nephropathy, only accounts for less than 20% of renal involvement

Insulin requirements are often reduced in diabetic nephropathy because the kidneys clear insulin from the blood of normal individuals.

Diabetic nephropathy is frequently associated with diabetic retinopathy and neuropathy.

There is increasing evidence that the risks of end-stage renal disease (need for dialysis) (ESRD) in type 1 and type 2 diabetes is lower than previously estimated:

  • ** a cohort study in type 1 diabetics was followed up for maximally 37 years, with a median of 16.7 years (1)
      • cumulative incidence of ESRD was 2.2% at 20 years and 7.8% at 30 years after diagnosis
      • risk of developing ESRD was lowest in patients whose diagnosis occurred at younger than 5 years
      • risk of ESRD was lower for patients diagnosed as having type 1 diabetes in later years of the study
  • *** a cohort study in type 2 diabetics has provided evidence that the individual risk of ESRD and chronic renal failure is low (2)
      • in this cohort, only 10 of 1,408 patients followed for 10 years developed ESRD, giving an incidence rate of 1.0 per 1,000 person-years, whereas cumulative risks for chronic renal failure adjusted for competing mortality were 6.1 and 9.3% after 20 and 30 years from diagnosis of diabetes, respectively.

The Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Management in CKD Guideline states:

  • glycemic management for patients with Type 2 diabetes (T2D) and CKD should include lifestyle therapy, first-line treatment with metformin and a sodium-glucose cotransporter-2 inhibitor (SGLT2i), and additional drug therapy as needed for glycemic control
    • KDIGO group concluded that most patients with diabetes, CKD, and eGFR >=30 ml/min per 1.73 m2 would benefit from treatment with both metformin, an inexpensive and generally well-tolerated medication that effectively lowers blood glucose, and an SGLT2i, which has been demonstrated to offer substantial benefits in reducing risks of CKD and CVD (cardiovascular disease)

  • in patients with T2D and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2i, or who are unable to use those medications, we recommend a long-acting glucagon-like peptide-1 receptor agonist (GLP-1 RA)


  1. Finn P et al. Incidence of end-stage renal disease in patients with type 1 diabetes.JAMA 2005;294:1782-7.
  2. Bruno G et al. Low incidence of end-stage renal disease and chronic renal failure in type 2 diabetes: a 10-year prospective study. Diabetes Care. 2003 Aug;26(8):2353-8.
  3. de Boer IH, Caramori ML, Chan JCN, Heerspink HJL, Hurst C, Khunti K, Liew A, Michos ED, Navaneethan SD, Olowu WA, Sadusky T, Tandon N, Tuttle KR, Wanner C, Wilkens KG, Zoungas S, Lytvyn L, Craig JC, Tunnicliffe DJ, Howell M, Tonelli M, Cheung M, Earley A, Rossing P. Executive summary of the 2020 KDIGO Diabetes Management in CKD Guideline: evidence-based advances in monitoring and treatment. Kidney Int. 2020 Oct;98(4):839-848