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BACKGROUND Thrombotic microangiopathy (TMA) has been associated with diabetic nephropathy, but its pathogenesis is unknown. OBJECTIVES To determine the role of vascular endothelial growth factor (VEGF) expression in patients with TMA and diabetes mellitus. MATERIALS AND METHODS Retrospective cohort study, patients were divided into diabetic nephropathy patients either without thrombotic microangiopathy (DN-TMA) or with thrombotic microangiopathy (DN+TMA). VEGF levels were analyzed using immunohistochemistry. Statistical analysis was performed with SPSS 20.0 software. RESULTS There were 36 patients included in this study with a mean age of 47.6 ± 9.3 years. The average time since the diagnosis of diabetes mellitus was 6.8 ± 4.1 years. There were 21 patients (58.3%) with DN+TMA and 15 patients (41.7%) with DN-TMA. Patients with DN+TMA had a higher systolic blood pressure (p = 0.014) and diastolic blood pressure (p < 0.001) as well as proteinuria (p = 0.006), and a lower rate of glomerular filtration at baseline (p = 0.01). VEGF assessment showed lower arteriolar and glomerular expression in patients with DN+TMA (p < 0.001). The VEGF expression levels had an inverse relationship with proteinuria (r = -0.373; p = 0.03) and were directly proportional with glomerular filtration (r = 0.712; p < 0.01). Kaplan-Meier curves showed a higher probability of end-stage renal disease in patients with DN+TMA (log-rank p < 0.012). CONCLUSION TMA is associated with low VEGF expression and end-stage renal disease in patients with diabetic nephropathy. .