CME information and disclosures
To see contributor disclosures related to this article, hover over this reference: 
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.
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 , including management of hypertension and ASCVD risk factors as needed.
- Affects up to 40% of adults with diabetes and is a major cause of ESRD 
- Onset varies depending on the type of diabetes: 
Epidemiological data refers to the US, unless otherwise specified.
Chronic hyperglycemia → glycation (also called or NEG) of the basement membrane () → 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 
Three major histological changes can be seen on light microscopy. 
- Mesangial expansion
- Glomerular basement membrane thickening
Glomerulosclerosis (later stages)
- Diffuse hyalinization (most common) or
- Pathognomonic nodular glomerulosclerosis (Kimmelstiel-Wilson nodules):
- Perform diagnostic studies for patients with positive results from .
- Diabetic kidney disease is confirmed through:
- All patients require .
- Refer patients with any of the following to nephrology for further evaluation: 
Laboratory studies 
- Glomerular filtration rate (see also “ ”)
Urine studies: spot 
- Perform in the morning if possible. 
- Urine albumin to creatinine ratio ≥ 30 mg/g is considered abnormal.
- Manage patients as part of a multidisciplinary team.
- Reduce the risk of further progression of CKD with:
- Initiate electrolyte abnormalities). and any associated complications (e.g.,
- because of the high risk of co-occurrence.
- Arrange scheduled follow-up for diabetic kidney disease.
- Refer to nephrology if patients experience worsening renal function or for assistance managing CKD complications.
Management of underlying risk factors
Modifications to kidney disease in diabetic
- Glycemic targets 
- T1DM: Insulin dosage may need to be reduced as eGFR declines ; monitor patients for hypoglycemia. 
|Treatment of T2DM in patients with CKD |
|eGFR ≥ 30 mL/min/1.73 m2|
|eGFR < 30 mL/min/1.73 m2|
|Patients with a kidney transplant|
Management of ASCVD risk factors for patients with diabetic kidney disease 
Patients should undergowith the following modifications for : 
Patients with albuminuria: for dosages see “Antihypertensive therapy.”
- First-line: RAS inhibitors ( or )
- Combination : Consider if blood pressure is not controlled with an RAS inhibitor. 
- Nonsteroidal mineralocorticoid receptor antagonists PLUS RAS inhibitor: for patients with persistent albuminuria refractory to therapy 
- Patients without albuminuria: : Initiate (i.e., RAS inhibitors, thiazide diuretics, or calcium channel blockers). 
Nonsteroidal mineralocorticoid receptor antagonists are associated with improved cardiovascular and renal outcomes. 
Management of CKD in patients with diabetes 
- Educate patients on diabetic kidney disease. 
- Provide nutritional advice; consider dietitian consultation. 
- Adjust the dosage of renally cleared medications based on eGFR and avoid nephrotoxins.
- Ensure patients are up-to-date on vaccinations (see “ ”). 
Follow-up for diabetic kidney disease
- Reassess ASCVD risk factors every 3–6 months. 
- Patients with eGFR ≥ 60 mL/min/1.73 m2 
- Patients with eGFR < 60 mL/min/1.73 m2: Regularly assess for . 
- Educate patients on diabetic kidney disease and the importance of attending screenings.
- Optimize to reach . 
- Treat underlying hypertension. 
- Avoid prescribing nephrotoxic medications. 
Screening for diabetic kidney disease 
- Onset 
- Recommended assessment