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October 8, 2003

Causes of Renal Failure in Patients With Type 2 Diabetes Mellitus

Author Affiliations

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

JAMA. 2003;290(14):1855-1856. doi:10.1001/jama.290.14.1855-a

In Reply: In response to Dr Kida, we are unaware of studies of atubular glomeruli among patients with diabetes and kidney disease but without albuminuria,1 but this is certainly an area that should be further investigated.

We disagree with Dr Onuigbo that a random single eye examination underestimated diabetic retinopathy in our data from the Third National Health and Nutrition Examination Survey (NHANES III). In the Wisconsin Epidemiologic Study of Diabetic Retinopathy, only 9% of the 991 subjects had diabetic retinopathy in 1 eye, while 63% had bilateral disease and the remaining subjects had no retinopathy (Ronald Klein, MD, MPH, Department of Ophthalmology and Visual Sciences, University of Wisconsin Medical School, Madison, unpublished data, November 4, 2002). We believe that a more likely reason for the higher incidence of retinopathy reported by Gall et al2 and Schwartz et al3 is referral bias. Gall et al studied patients attending a diabetes clinic, and the study by Schwartz et al included patients with type 2 diabetes with proteinuria of greater than 0.5 g/d. Thus, it is not surprising that disease burden was higher in these referral populations. The NHANES III data that we used are from a nationally representative survey and therefore reflect the true burden of disease in the general US population. All the patients in the study by Nosadini and colleagues4 had microalbuminuria or macroalbuminuria. The relevance of these findings to our results is unclear, as we focused on patients with decreased GFR in the absence of microalbuminuria or macroalbuminuria. Early intervention is beneficial in patients with diabetes mellitus. Further research is clearly needed to understand how and why, as reported by Tsalamandris et al, some patients with diabetes lose renal function in the absence of albuminuria.

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