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Aims To assess and compare the risk of adverse renal events among patients with diabetic macular oedema (DME) who were treated with either intravitreal ranibizumab or aflibercept in Taiwan.Methods We conducted a population-based retrospective cohort study and employed a target trial emulation framework using Taiwan’s National Health Insurance Database from 2011 to 2018.Patients aged over 20 years diagnosed with DME and receiving treatment with either intravitreal aflibercept or ranibizumab were included. We applied propensity score methods to ensure balance in the baseline characteristics between the two treatment groups. The primary outcomes were the adverse renal events, specifically acute renal injury and hospitalisation due to renal events. We employed Cox proportional hazards models to estimate the HRs associated with these outcomes.Results A total of 6330 patients receiving ranibizumab and 1258 patients receiving aflibercept were included in this study. The incidence rates of adverse renal events were 102.2 and 138.7 per 1000 person-years for ranibizumab and aflibercept, respectively. Patients treated with intravitreal aflibercept had a significantly higher risk of experiencing a composite of adverse renal events (HR: 1.42; 95% CI: 1.24 to 1.63), compared with those treated with ranibizumab, and specifically also a higher risk of acute kidney injury (HR: 1.32; 95% CI: 1.08 to 1.63) and hospitalisation due to renal events (HR: 1.43; 95% CI: 1.25 to 1.64).Conclusion In comparison to ranibizumab, the intravitreal use of aflibercept was associated with a greater risk of adverse renal events. These findings provide a solid foundation for future studies to validate these results further.