Diabetic nephropathy has become the most common single cause of Established Renal Failure (ERF) in the United States of America (USA) and Europe. In the United Kingdom (UK) diabetic nephropathy is seen in 18% of new patients requiring dialysis. In the USA 7.3% of all adults and 17.8% of those over 65 years have diabetes mellitus. Furthermore diabetic nephropathy is the cause of ERF in up to 45% of patients on dialysis. Recently compiled data by the World Health Organisation (WHO) shows that approximately 150 million people worldwide have diabetes and predict that this number may well have doubled to 300 million by 2025. These figures are clearly daunting and renal units must prepare themselves for the rising number of patients with diabetes needing renal replacement therapy (RRT) in the future. Renal specialist nurses do not always have a major role to play in the prevention of diabetic nephropathy. Their remit must be to try and delay the progression to ERF and perhaps more importantly to concentrate their efforts on their ERF patient population with diabetes that have co-existing diabetes related pathologies. This article will attempt to discuss how renal nurses can best expand/extend their skills and knowledge to provide effective care for this patient group, and explore whether developing new and innovative roles or just new ways of working is the way forward.