Diabetic nephropathy is a leading cause of chronic kidney disease (CKD) in the UK. These patients are at significantly increased risk of cardiovascular disease and of progression to end-stage renal disease. We review the epidemiology, pathogenesis and natural history of diabetic nephropathy and evaluate the therapeutic options available.We searched Medline and PubMed for source articles relevant to diabetic nephropathy and CKD.Early multifactorial intervention including strict blood pressure control, the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin two-receptor blockers (A2RB's) and good metabolic control attenuates cardiovascular risk and slows the rate of progression of renal disease.Current areas of uncertainty include the relative benefits of ACE inhibitors and A2RBs in combination, whether direct renin inhibitors are harmful in patients with diabetes and also the positioning of hypoglycaemic agents as renal function declines.What are the appropriate metabolic and blood pressure targets for patients with diabetes? AREAS TIMELY FOR DEVELOPMENT: Therapeutic strategies as kidney function declines.