Type 2 diabetes is the leading cause of end-stage kidney disease in the United States. The management of patients with type 2 diabetes and progressive kidney disease requires a comprehensive approach that includes aggressive blood pressure control with agents that also lower urinary protein excretion and optimization of glucose and lipid control while remaining cognizant of the therapeutic limitations imparted by renal dysfunction. Clinicians must also address the comorbidities associated with renal failure such as anemia and secondary hyperparathyroidism. Diabetic nephropathy typically follows a slowly progressive course from albuminuria to azotemia. Consequently, optimal care includes planning for the management of impending renal failure long before the patient requires dialysis or transplantation.