Pregnancy is a renal “stress test” as the normal physiology of pregnancy demands increased renal blood flow in parallel with systemic cardiovascular changes, sodium and water retention and changes to the collecting system promoting urine stasis. Diabetes is a common cause of the entire spectrum of kidney disease from persistent albuminuria with normal renal function (Stage 1) to end stage kidney disease (Stage 5) and renal transplantation. In turn, during pregnancy the entire spectrum of kidney disease substantially increases the risk of adverse maternal and fetal outcomes including pre-eclampsia, temporary or permanent decline in renal function, pre-term delivery, fetal growth restriction and fetal death, in a continuous manner that parallels increasing degrees of renal dysfunction. A permanent decline in renal function and progression to end stage renal disease as a result of pregnancy is a very real possibility in women with significant chronic kidney disease. While fertility is impaired in women with advanced renal disease, pregnancy is common in women with mild to moderate degrees of renal dysfunction or a well-functioning renal transplant. Thus, an adequate assessment of renal function, blood pressure and albuminuria/proteinuria followed by preconception counselling is mandatory in women with diabetes who may be considering pregnancy. Occasionally, a renal biopsy or other additional investigations may be needed when other causes of renal disease are suspected. Kidney donation also increases the risk of hypertensive disease of pregnancy in the donor during a subsequent pregnancy, therefore consideration of child bearing plans forms an integral part of live donor assessment for all renal transplant recipients, including women with diabetes.