Kidney Disease 

of Diabetes 

National Kidney and Urologic Diseases Information Clearinghouse 

The Burden of Kidney 

Failure 

Each year in the United States, more than 

100,000 people are diagnosed with kidney 

failure, a serious condition in which the 

kidneys fail to rid the body of wastes.1 

Kidney failure is the final stage of chronic 

kidney disease (CKD). 

Diabetes is the most common cause of 

kidney failure, accounting for nearly 

44 percent of new cases.1 Even when 

diabetes is controlled, the disease can lead 

to CKD and kidney failure. Most people 

with diabetes do not develop CKD that is 

severe enough to progress to kidney failure. 

Nearly 24 million people in the United 

States have diabetes,2

 and nearly 180,000 

people are living with kidney failure as a 

result of diabetes.1 

People with kidney failure undergo either 

dialysis, an artificial blood-cleaning process, 

or transplantation to receive a healthy 

kidney from a donor. Most U.S. citizens 

who develop kidney failure are eligible for 

federally funded care. In 2005, care for 

patients with kidney failure cost the United 

States nearly $32 billion.1 

1

United States Renal Data System. USRDS 2007 

Annual Data Report. Bethesda, MD: National Institute 

of Diabetes and Digestive and Kidney Diseases, 

National Institutes of Health, U.S. Department of 

Health and Human Services; 2007. 

2

National Institute of Diabetes and Digestive and 

Kidney Diseases. National Diabetes Statistics, 2007. 

Bethesda, MD: National Institutes of Health, U.S. 

Department of Health and Human Services, 2008. 

African Americans, American Indians, and 

Hispanics/Latinos develop diabetes, CKD, 

and kidney failure at rates higher than 

Caucasians. Scientists have not been able 

to explain these higher rates. Nor can they 

explain fully the interplay of factors leading 

to kidney disease of diabetes—factors 

including heredity, diet, and other medical 

conditions, such as high blood pressure. 

They have found that high blood pressure 

and high levels of blood glucose increase 

the risk that a person with diabetes will 

progress to kidney failure.

Primary Causes 


of Kidney Failure (2005)
 

2.3% Cystic 

diseases 

2.0% Urologic 

diseases 

26.8% 

High 

blood 

pressure 

7.6% 

Glomerulonephritis 

17.5% 

Other 

43.8% 

Diabetes 

Source: United States Renal Data System. USRDS 

2007 Annual Data Report.
The Course of Kidney 

Disease 

Diabetic kidney disease takes many years 

to develop. In some people, the filtering 

function of the kidneys is actually higher 

than normal in the first few years of their 

diabetes. 

Over several years, people who are 

developing kidney disease will have small 

amounts of the blood protein albumin begin 

to leak into their urine. This first stage 

of CKD is called microalbuminuria. The 

kidney’s filtration function usually remains 

normal during this period. 

As the disease progresses, more albumin 

leaks into the urine. This stage may be 

called macroalbuminuria or proteinuria. 

As the amount of albumin in the urine 

increases, the kidneys’ filtering function 

usually begins to drop. The body retains 

various wastes as filtration falls. As kidney 

damage develops, blood pressure often 

rises as well. 

Overall, kidney damage rarely occurs in 

the first 10 years of diabetes, and usually 

15 to 25 years will pass before kidney failure 

occurs. For people who live with diabetes 

for more than 25 years without any signs of 

kidney failure, the risk of ever developing it 

decreases. 

Diagnosis of CKD 

People with diabetes should be screened 

regularly for kidney disease. The two key 

markers for kidney disease are eGFR and 

urine albumin. 

• 	 eGFR. eGFR stands for estimated 

glomerular filtration rate. Each kidney 

contains about 1 million tiny filters 

made up of blood vessels. These filters 

are called glomeruli. Kidney function 

can be checked by estimating how 

much blood the glomeruli filter in a 

minute. The calculation of eGFR is 

based on the amount of creatinine, 

a waste product, found in a blood 

sample. As the level of creatinine goes 

up, the eGFR goes down. 

Kidney disease is present when eGFR 

is less than 60 milliliters per minute. 

The American Diabetes Association 

(ADA) and the National Institutes of 

Health (NIH) recommend that eGFR 

be calculated from serum creatinine 

at least once a year in all people with 

diabetes. 

• 	Urine albumin. Urine albumin is 

measured by comparing the amount of 

albumin to the amount of creatinine 

in a single urine sample. When the 

kidneys are healthy, the urine will 

contain large amounts of creatinine 

but almost no albumin. Even a small 

increase in the ratio of albumin to 

creatinine is a sign of kidney damage. 

2 	 Kidney Disease of Diabetes 
Kidney disease is present when urine 

contains more than 30 milligrams of 

albumin per gram of creatinine, with 

or without decreased eGFR.

The ADA and the NIH recommend 

annual assessment of urine albumin 

excretion to assess kidney damage in 

all people with type 2 diabetes and 

people who have had type 1 diabetes 

for 5 years or more.

If kidney disease is detected, it should 

be addressed as part of a comprehensive 

approach to the treatment of diabetes.

Effects of High Blood 

Pressure

High blood pressure, or hypertension, is a 

major factor in the development of kidney 

problems in people with diabetes. Both 

a family history of hypertension and the 

presence of hypertension appear to increase 

chances of developing kidney disease. 

Hypertension also accelerates the progress 

of kidney disease when it already exists.

Blood pressure is recorded using two 

numbers. The first number is called 

the systolic pressure, and it represents 

the pressure in the arteries as the heart 

beats. The second number is called the 

diastolic pressure, and it represents the 

pressure between heartbeats. In the past, 

hypertension was defined as blood pressure 

higher than 140/90, said as “140 over 90.”

Hypertension can be seen not only as 

a cause of kidney disease but also as a 

result of damage created by the disease. 

As kidney disease progresses, physical 

changes in the kidneys lead to increased 

blood pressure. Therefore, a dangerous 

spiral, involving rising blood pressure and 

factors that raise blood pressure, occurs. 

Early detection and treatment of even mild 

hypertension are essential for people with 

diabetes.

Preventing and Slowing 

Kidney Disease

Blood Pressure Medicines

Scientists have made great progress in 

developing methods that slow the onset 

and progression of kidney disease in 

people with diabetes. Drugs used to lower 

blood pressure can slow the progression 

of kidney disease significantly. Two types 

of drugs, angiotensin-converting enzyme 

(ACE) inhibitors and angiotensin receptor 

blockers (ARBs), have proven effective in 

slowing the progression of kidney disease. 

Many people require two or more drugs to 

control their blood pressure. In addition 

to an ACE inhibitor or an ARB, a diuretic 

can also be useful. Beta blockers, calcium 

channel blockers, and other blood pressure 

drugs may also be needed.

3 Kidney Disease of Diabetes
4 

An example of an effective ACE inhibitor 

is lisinopril (Prinivil, Zestril), which 

doctors commonly prescribe for treating 

kidney disease of diabetes. The benefits of 

lisinopril extend beyond its ability to lower 

blood pressure: it may directly protect 

the kidneys’ glomeruli. ACE inhibitors 

have lowered proteinuria and slowed 

deterioration even in people with diabetes 

who did not have high blood pressure. 

An example of an effective ARB is losartan 

(Cozaar), which has also been shown to 

protect kidney function and lower the risk 

of cardiovascular events. 

Patients with even mild hypertension or 

persistent microalbuminuria should consult 

a health care provider about the use of 

antihypertensive medicines. 

Moderate-protein Diets 

In people with diabetes, excessive 

consumption of protein may be harmful. 

Experts recommend that people with 

kidney disease of diabetes consume the 

recommended dietary allowance for 

protein, but avoid high-protein diets. 

For people with greatly reduced kidney 

function, a diet containing reduced 

amounts of protein may help delay the 

onset of kidney failure. Anyone following 

a reduced-protein diet should work with a 

dietitian to ensure adequate nutrition. 

Intensive Management 

of Blood Glucose 

Antihypertensive drugs and low-protein 

diets can slow CKD. A third treatment, 

known as intensive management of blood 

glucose or glycemic control, has shown 

great promise for people with diabetes, 

especially for those in the early stages of 

CKD. 

The human body normally converts food 

to glucose, the simple sugar that is the 

main source of energy for the body’s 

cells. To enter cells, glucose needs the 

help of insulin, a hormone produced by 

the pancreas. When a person does not 

make enough insulin, or the body does not 

respond to the insulin that is present, the 

body cannot process glucose, and it builds 

up in the bloodstream. High levels of 

glucose in the blood lead to a diagnosis of 

diabetes. 

Intensive management of blood glucose 

is a treatment regimen that aims to keep 

blood glucose levels close to normal. 

The regimen includes testing blood 

glucose frequently, administering insulin 

throughout the day on the basis of food 

intake and physical activity, following a diet 

and activity plan, and consulting a health 

care team regularly. Some people use an 

insulin pump to supply insulin throughout 

the day. 

A number of studies have pointed to the 

beneficial effects of intensive management 

of blood glucose. In the Diabetes Control 

and Complications Trial supported by 

the National Institute of Diabetes and 

Digestive and Kidney Diseases (NIDDK), 

researchers found a 50 percent decrease 

in both development and progression of 

early diabetic kidney disease in participants 

who followed an intensive regimen for 

4 Kidney Disease of Diabetes 
5 Kidney Disease of Diabetes

controlling blood glucose levels. The 

intensively managed patients had average 

blood glucose levels of 150 milligrams 

per deciliter—about 80 milligrams per 

deciliter lower than the levels observed in 

the conventionally managed patients. The 

United Kingdom Prospective Diabetes 

Study, conducted from 1976 to 1997, 

showed conclusively that, in people with 

improved blood glucose control, the risk of 

early kidney disease was reduced by a third. 

Additional studies conducted over the past 

decades have clearly established that any 

program resulting in sustained lowering of 

blood glucose levels will be beneficial to 

patients in the early stages of CKD.

Dialysis and Transplantation

When people with diabetes experience 

kidney failure, they must undergo either 

dialysis or a kidney transplant. As recently 

as the 1970s, medical experts commonly 

excluded people with diabetes from dialysis 

and transplantation, in part because the 

experts felt damage caused by diabetes 

would offset benefits of the treatments. 

Today, because of better control of diabetes 

and improved rates of survival following 

treatment, doctors do not hesitate to offer 

dialysis and kidney transplantation to 

people with diabetes.

Currently, the survival of kidneys 

transplanted into people with diabetes 

is about the same as the survival of 

transplants in people without diabetes. 

Dialysis for people with diabetes also works 

well in the short run. Even so, people with 

diabetes who receive transplants or dialysis 

experience higher morbidity and mortality 

because of coexisting complications of 

diabetes—such as damage to the heart, 

eyes, and nerves.

5 Kidney Disease of Diabetes

Good Care Makes 

a Difference

People with diabetes should

• have their health care provider 

measure their A1C level at least 

twice a year. The test provides a 

weighted average of their blood 

glucose level for the previous 

3 months. They should aim to 

keep it at less than 7 percent.

• work with their health care provider 

regarding insulin injections, 

medicines, meal planning, physical 

activity, and blood glucose 

monitoring.

• have their blood pressure checked 

several times a year. If blood pressure 

is high, they should follow their health 

care provider’s plan for keeping it 

near normal levels. They should aim 

to keep it at less than 140/90.

• ask their health care provider whether

they might benefit from taking an 

ACE inhibitor or ARB.

• ask their health care provider to

measure their eGFR at least once a

year to learn how well their kidneys

are working.

• ask their health care provider to 

measure the amount of protein in 

their urine at least once a year to 

check for kidney damage.

• ask their health care provider whether

they should reduce the amount of 

protein in their diet and ask for a 

referral to see a registered dietitian 

to help with meal planning. 
Points to Remember 

• 	Diabetes is the leading cause of

chronic kidney disease (CKD) and

kidney failure in the United States.

• 	People with diabetes should be

screened regularly for kidney disease.

The two key markers for kidney

disease are estimated glomerular

filtration rate (eGFR) and urine

albumin.

• 	Drugs used to lower blood pressure

can slow the progression of kidney

disease significantly. Two types

of drugs, angiotensin-converting

enzyme (ACE) inhibitors and

angiotensin receptor blockers

(ARBs), have proven effective in

slowing the progression of kidney

disease.

• 	In people with diabetes, excessive

consumption of protein may be

harmful.

• 	Intensive management of blood

glucose has shown great promise for

people with diabetes, especially for

those in the early stages of CKD.

Hope through Research 

The number of people with diabetes is 

growing. As a result, the number of people 

with kidney failure caused by diabetes 

is also growing. Some experts predict 

that diabetes soon might account for half 

the cases of kidney failure. In light of 

the increasing illness and death related 

to diabetes and kidney failure, patients, 

researchers, and health care professionals 

will continue to benefit by addressing the 

relationship between the two diseases. The 

NIDDK is a leader in supporting research 

in this area. 

Several areas of research supported by the 

NIDDK hold great potential. Discovery 

of ways to predict who will develop kidney 

disease may lead to greater prevention, as 

people with diabetes who learn they are at 

risk institute strategies such as intensive 

management of blood glucose and blood 

pressure control. 

Clinical trials are research studies involving 

people. Clinical trials look at safe and 

effective new ways to prevent, detect, or 

treat disease. Researchers also use clinical 

trials to look at other aspects of care, such 

as improving the quality of life for people 

with chronic illnesses. To learn more about 

clinical trials, why they matter, and how to 

participate, visit the NIH Clinical Research 

Trials and You website at www.nih.gov/ 

health/clinicaltrials. For information about 

current studies, visit www.ClinicalTrials.gov. 

6 Kidney Disease of Diabetes 
For More Information 

National Diabetes Information 

Clearinghouse 

1 Information Way 

Bethesda, MD 20892–3560 

Phone: 1–800–860–8747 

TTY: 1–866–569–1162 

Fax: 703–738–4929 

Email: ndic@info.niddk.nih.gov 

Internet: www.diabetes.niddk.nih.gov 

National Diabetes Education Program 

1 Diabetes Way 

Bethesda, MD 20814–9692 

Phone: 1–888–693–NDEP 

(1–888–693–6337) 

TTY: 1–866–569–1162 

Fax: 703–738–4929 

Email: ndep@mail.nih.gov 

Internet: www.ndep.nih.gov 

www.yourdiabetesinfo.org 

National Kidney Disease 

Education Program 

3 Kidney Information Way 

Bethesda, MD 20892 

Phone: 1–866–4–KIDNEY 

(1–866–454–3639) 

TTY: 1–866–569–1162 

Fax: 301–402–8182 

Email: nkdep@info.niddk.nih.gov 

Internet: www.nkdep.nih.gov 

American Diabetes Association 

1701 North Beauregard Street 

Alexandria, VA 22311 

Phone: 1–800–DIABETES 

(1–800–342–2383) 

Email: askADA@diabetes.org 

Internet: www.diabetes.org 

National Kidney Foundation 

30 East 33rd Street 

New York, NY 10016–5337

Phone: 1–800–622–9010 or 212–889–2210 

Fax: 212–689–9261 

Internet: www.kidney.org 

Acknowledgments 

Publications produced by the Clearinghouse 

are carefully reviewed by both NIDDK 

scientists and outside experts. 

7 Kidney Disease of Diabetes 
National Kidney Disease 

Education Program 

3 Kidney Information Way 

Bethesda, MD 20892 

Phone: 1–866–4–KIDNEY 

(1–866–454–3639) 

TTY: 1–866–569–1162 

Fax: 301–402–8182 

Email: nkdep@info.niddk.nih.gov 

Internet: www.nkdep.nih.gov 

The National Kidney Disease Education 

Program (NKDEP) is an initiative of 

the National Institute of Diabetes and 

Digestive and Kidney Diseases, National 

Institutes of Health, U.S. Department of 

Health and Human Services. The NKDEP 

aims to raise awareness of the seriousness 

of kidney disease, the importance of testing 

those at high risk, and the availability of 

treatment to prevent or slow kidney disease. 

You may also find additional information about this 

topic by visiting MedlinePlus at www.medlineplus.gov. 

This publication may contain information about 

medications and, when taken as prescribed, 

the conditions they treat. When prepared, this 

publication included the most current information 

available. For updates or for questions about 

any medications, contact the U.S. Food and Drug 

Administration toll-free at 1–888–INFO–FDA 

(1–888–463–6332) or visit www.fda.gov. Consult your 

health care provider for more information. 

The U.S. Government does not endorse or favor any 

specific commercial product or company. Trade, 

proprietary, or company names appearing in this 

document are used only because they are considered 

necessary in the context of the information provided. 

If a product is not mentioned, the omission does not 

mean or imply that the product is unsatisfactory. 

National Kidney and 

Urologic Diseases 

Information Clearinghouse 

3 Information Way 

Bethesda, MD 20892–3580 

Phone: 1–800–891–5390 

TTY: 1–866–569–1162 

Fax: 703–738–4929 

Email: nkudic@info.niddk.nih.gov 

Internet: www.kidney.niddk.nih.gov 

The National Kidney and Urologic Diseases 

Information Clearinghouse (NKUDIC) 

is a service of the National Institute of 

Diabetes and Digestive and Kidney Diseases 

(NIDDK). The NIDDK is part of the 

National Institutes of Health of the U.S. 

Department of Health and Human Services. 

Established in 1987, the Clearinghouse 

provides information about diseases of the 

kidneys and urologic system to people with 

kidney and urologic disorders and to their 

families, health care professionals, and the 

public. The NKUDIC answers inquiries, 

develops and distributes publications, and 

works closely with professional and patient 

organizations and Government agencies 

to coordinate resources about kidney and 

urologic diseases. 

This publication is not copyrighted. The Clearinghouse 

encourages users of this publication to duplicate and 

distribute as many copies as desired. 

This publication is available at 

www.kidney.niddk.nih.gov. 

NIH Publication No. 14–3925 

February 2014

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