A rising frequency of diabetic kidney disease worldwide is disproportionately affecting disadvantaged people. Among the hardest hit are people in the poorest countries, which lack the public health infrastructure to address the epidemic using treatments widely available in the developed world. In this article, Robert Nelson examines the frequency of diabetic kidney disease in various parts of the world, explores some reasons why disadvantaged populations may be particularly vulnerable to this complication of diabetes, and describes how health-care providers may successfully address this problem despite limited resources.