/ORIGINAL CONTRIBUTION Renal Insufficiency in the Absence of Albuminuria and Retinopathy Among Adults With Type 2 Diabetes Mellitus

END-STAGE RENAL DISEASE (ESRD) in adults with type 2 diabetes mellitus (DM) represents a medical problem with worldwide dimensions. Currently, approximately 40% of all prevalent ESRD cases and almost half of all new cases in the United States are attributed to type 2 DM. Due to the increasing incidence of type 2 DM and the increased survival of these individuals due to improved medical treatment, the number of patients with ESRD is expected to double over the next decade, with costs escalating to $28 billion. Most of our knowledge concerning the nature of kidney disease in adults with type 2 DM is derived from studies of patients with type 1 DM. The classic clinical course of type 1 diabetic nephropathy (glomerulosclerosis) is described as the development of microalbuminuria, which eventually leads to macroalbuminuria and then to progressive loss of glomerular filtration rate (GFR). Among adults with type 1 DM and nephropathy, more than 95% will have diabetic retinopathy. The extent to which renal disease in adults with type 2 DM is a consequence of classic diabetic glomerulosclerosis remains controversial. Biopsy series among those with macroalbuminuria (or some other clinical indication for a biopsy, such as active urine sediment or a rapidly rising creatinine level) has been a major source of knowledge concerning the distribution of renal pathology in persons with type 2 DM. Autopsy series and clinical examination of patients presenting for renal replacement therapy have also provided valuable information. However, by their nature, these studies may