For the past 24 years, a 70-year-old man has had hemoglobin A1c values between 8% and 11%. On physical examination, he has hard exudates and cotton-wool spots, as well as foci of neovascularization, seen on funduscopy. He now has increasing serum urea nitrogen and creatinine levels as well as proteinuria. Which of the following pathologic findings on renal biopsy is most likely to be present?
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