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Simple Summary: Diabetic nephropathy is a common cause of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) worldwide and results in tremendous wastage of medical resources. Determining the indicators of diabetic nephropathy, such as sarcopenia, and implementing early interventions to prevent disease progression is crucial. The effect of sarcopenia on the risk of severe diabetic nephropathy in patients with type 2 diabetes (T2DM) remains unclear. This study, to date, has the largest sample size and the longest follow-up period among studies investigating this effect by comparing patients with T2DM with and without sarcopenia. This propensity score–matched, population-based cohort study demonstrated that patients with T2DM and sarcopenia may be at a higher risk of severe diabetic nephropathy than are those without sarcopenia. The patients with T2DM and sarcopenia were at a higher risk of severe diabetic nephropathy than were those without sarcopenia irrespective of age, sex, and diabetes severity. Our results may serve as a valuable reference for relevant government authorities in establishing health policies promoting early detection of sarcopenia and exercise to help patients with T2DM overcome sarcopenia. Background: Diabetic nephropathy is a common cause of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) worldwide and results in tremendous wastage of medical resources. Determining the indicators of diabetic nephropathy, such as sarcopenia, and implementing early interventions to prevent disease progression is crucial. Purpose: The effect of sarcopenia on the risk of severe diabetic nephropathy in patients with type 2 diabetes (T2DM) remains unclear. Patients and Methods: We recruited patients with T2DM and categorized them into two groups, propensity score–matched at a ratio of 1:1, according to whether they had sarcopenia. We subsequently compared the groups' risk of severe diabetic nephropathy. Results: The matching process yielded a final cohort of 105,166 patients with T2DM (52,583 and 52,583 in the sarcopenia and nonsarcopenia groups, respectively) who were eligible for inclusion in subsequent analyses. According to both the univariate and multivariate Cox regression analyses, the adjusted hazard ratio (aHR) (95% confidence interval) of severe diabetic nephropathy for the sarcopenia diabetes group compared with the control group was 1.10 (1.08–1.13; p < 0.001). Conclusion: The patients with T2DM and sarcopenia were at a higher risk of severe diabetic nephropathy than were those without sarcopenia. Our results may serve as a valuable reference for relevant government authorities in establishing health policies to promote early detection of sarcopenia and exercise to help patients with T2DM overcome sarcopenia. [ABSTRACT FROM AUTHOR]