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To The Editor: Dr Kramer and colleagues¹ reported that among adults with type 2 diabetes and renal failure (defined as a glomerular filtration rate [GFR] less than 60mL/min per 1.73 m² body surface area), 30% had neither retinopathy nor albuminuria.

The concept of "atubular glomeruli" could help account for the lack of vascular damage in the eye or kidney despite the apparent presence of renal injury. The concept proposes that damage occurs first at the renal tubule and then later at the glomerulus.² Collapse of the tubule can lead to the obstruction of the tubule lumen, and thus prevents efflux of the glomerular filtrate from the Bowman capsule.² It is possible that atubular glomeruli would be found in patients with type 2 diabetes and chronic renal insufficiency (CRI), but without retinopathy or albuminuria.

Yujiro Kida, MD, PhD
Department of Internal Medicine
Tokyo Metropolitan Komagome Hospital
Tokyo, Japan

1. Kramer HJ, Nguyen QD, Curhan G, Hsu C. Renal insufficiency in the absence of albuminuria and retinopathy among adults with type 2 diabetes mellitus. JAMA. 2003;289:3273-3277. FREE FULL TEXT 2. Kriz W, Hosser H, Hahnel B, et al. From segmental glomerulosclerosis to total nephron degeneration and interstitial fibrosis. Nephrol Dial Transplant. 1998;13:2781-2798. FREE FULL TEXT

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;290:1855.

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