Review

Intercapillary Glomerulosclerosis: A Clinical

and Pathologic Study

I. Spec;ficig of the Clinical Syndrome*

JOSEPH ROGERS, M.D. and STANLEY L. ROBBINS, M.D.

Boston, Massachusetts

F OURTEEN years ago Kimmelstiel and Wil- son1 reported a series of eight cases that presented a peculiar type of renal lesion

to which they applied the term intercapillary glomerulosclerosis. Seven of the patients were known diabetics; the last, having insufficient clinical data at the time of death, was never established as a diabetic. All of the patients had hypertension and albuminuria.

Since that time considerable controversy has arisen over the specificity not only of the histo- logic lesion but also over the integrity of the clinical entity. Many observers2-6 have con- sidered the renal lesion specific for diabetes or at least sufficiently characteristic to suspect strongly the clinical presence of diabetes. Others7-* have disagreed with this view. Horn and Smetanag stated that “although intercapil- lary glomerulosclerosis in its more advanced state is seen only in cases of diabetes, it is not of necessity associated with a particular clinical syndrome which includes diabetes mellitus.” They found an incidence of 25.4 per cent of intercapillary glomerulosclerosis in cases of arteriolar nephrosclerosis without diabetes.

Much of the confusion has arisen on strictly morphologic grounds. The original description by Kimmelstiel and Wilson made reference to a peculiar distribution of globular pink hyaline masses about the periphery of the vascular tufts of the glomerulus. These hyaline masses were distinct in having an apparent intercapillary position, thus pushing ahead of them as they increased in size intact patent capillary loops which thus formed “halos” about these masses. Since this original description many observers and Kimmelstiel himself have come to use the

term intercapillary glomerulosclerosis in a more general sense to imply any form of glomerular fibrosis found in the mesangium of the glomer- ular tuft. Such a general descriptive use of the term has necessarily included a great variety of degenerative lesions that affect the glomerular tuft, most particularly, nephro- sclerotic and arteriosclerotic changes as well as the characteristic Kimmelstiel-Wilson lesion.

In our experience, however, it appears pos- sible to separate these two types of intercapillary glomerulosclerosis into a non-specific diffuse variety and a distinct nodular peripheral variety which, it is our contention, remains characteristically associated with diabetes and is a pathognomonic feature of this disease entity. Such a distinction has been suggested by Kimmelstiel and Porter in their recent report. lo

Granted that there may be cases of inter- capillary glomerulosclerosis whose clinical in- vestigation is insufficient either to establish or for that matter to rule out the diagnosis of diabetes, in our experience the presence of diabetes mellitus correlates too closely with the specific histologic findings not to consider the lesion pathognomonic. The consideration of the anatomic aspects of this problem will be taken up in a later article, the present paper con- cerning itself only with the problem of whether a clinical entity can be distinguished.

From the clinical standpoint much confusion exists over the question of the diagnostic specific- ity of this syndrome. The earlier papers2~3~5~11-13 suggested a definite clinically recognizable syn- drome. 0thers4~7-g~14~ l5 questioned the existence of clinical characteristics sufficiently constant

* From the First and Third Medical Services, Boston City Hospital, Department of Medicine, Tufts College Medical School and the Mallory Institute of Pathology, Boston City Hospital, Boston, Mass.

688 AMERICAN JOURNAL OF MEDICINE

Intercapillary Glomerulosclerosis, I-Rogers, Robbins

to warrant establishing a clinical diagnosis. More recently Rifkin et aLi6 and Mann, Gard- ner and Root’? have expressed the opinion that a distinct clinical picture is associated with intercapillary glomerulosclerosis.

It is not widely appreciated that the original description referred only to a specific pathologic entity to which a more or less characteristic group of clinical features was attached. Hence from the outset the Kimmelstiel-Wilson syn- drome has not been a sharply defined clinical entity. The fact that this original description contained one case in which the diagnosis of diabetes was not established has given rise to the belief that diabetes mellitus is an inconstant feature. Moreover, hypertension and albumi- nuria are such common characteristics of patients of advanced age that these findings are of little diagnostic or differential significance. Thus the clinical entity has remained poorly delineated to the present time.

This clinical problem has been attacked by two methods. In this article a large group of diabetic patients were evaluated from the clinical standpoint alone. Specifically it was desired to attempt to select on purely clinical grounds out of a group of known diabetics those patients who would show the lesion of intercapillary glomerulosclerosis at autopsy. No non-diabetic cases were reviewed because, in our opinion, in the absence of this clinical finding no syndrome of intercapillary glomerulo- sclerosis can be said to exist. It was thus hoped to put to critical test any so-called diagnostic or pathognomonic criteria or symptom complexes. These results were then correlated with the postmortem findings and the diagnostic validity of the various features evaluated.

In a separate report to follow 100 established cases of this lesion have been analyzed clinically. In order to highlight the diagnostic worth of the various clinical features comparisons were made with a large group of diabetic patients known not to have intercapillary glomerulosclerosis. l8

METHODS

The clinical records of patients with diabetes mellitus autopsied at the Mallory Institute of Pathology at the Boston City Hospital during the years 1934 to 1946 were reviewed. At the time of the review the anatomic diagnoses were completely unknown to one of us (J. R.). Ex- cluding those cases in which insufficient clinical

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data were available for adequate evaluation, 229 were suitable for study.

The criteria established for selecting the cases of intercapillary glomerulosclerosis were based on the more or less accepted features of albumi- nuria, hypertension, edema and diabetes. Dia-

TABLE I CLINICAL FINDINGS REQUIRED FOR “PROBABLE” DIAGNOSIS

OF INTERCAPILLARY CLOMERULAR SCLEROSIS

Albuminuria Hypertension Edema

2-4 + 3-4+

Minimal to marked Generalized Minimal to marked Dependent

Clinical Findings Required for “Possible” Diagnosis of Intercapillary Glomerular Sclerosis

3+ 4+

I / Moderate to marked None

Minimal to marked None

betes was considered to be present if a fasting blood sugar had been 140 or over and some glycosuria had been present. They were then separated into “probable” and “possible” cate- gories based on the following clinical standards. (Table I.)

Although numerous instances of intercapil- lary glomerulosclerosis are reported in which albuminuria is absent or present in only 1 or 2 plus amount, the majority of cases reported have had at least 3 or 4 plus albuminuria. Moreover, previous clinical experience has led us to the belief that of the classic triad, next to diabetes albuminuria is the most significant diagnostic finding in the Kimmelstiel-Wilson syndrome. Hence 3 to 4 plus albuminuria was demanded as a requisite for the diagnosis to be “probable.” It was moreover decided that accompanying this albuminuria there must be some edema and some hypertension. When a generalized nephrotic type edema was present, a 2 plus albuminuria was considered adequate. Hyper- tension was divided into three grades of severity as follows: minimal when the systolic pressure ranged from 140 to 170 mm. and the diastolic was 90 mm.; moderate when the systolic pres- sure ranged from 140 to 190 mm. and the diastolic 90 to 115 mm.; and marked when the systolic pressure was 490 mm. or higher and the diastolic 115 mm. or higher. Hypertension was, in our opinion, the most variable and least significant as a diagnostic aid. The age group

690 Intercapillary Glomerulosclerosis, I-Rogers, Robbins

of patients under consideration is more than likely to have varying degrees of hypertension totally unrelated to any specific renal lesion.

In the absence of edema but with the pre- viously cited 3 to 4 plus albuminuria two sets of criteria were established for those cases in which

TABLE II

Results in Cases Listed as “Probable” Clinical Findi, ‘!3

-

Alhuminuria Hypertension Edema

Z--4+

3-4+

Total

Minimal to Generalized marked

Minimal to Dependent marked

/ -

No. No. of OX-

Cases rect

4 3

22 17

26 20

-___ 6 24

R~.rults in Cases Listed as “Possible” (:linical Findings:

I

No. Albuminuria Hypertension Edema of ;o;_ z: ,zt

Cases rrct yz;; Error

- .___

3f Moderate to None 6 2 4 marked

4+ Minimal to None 9 6 3 moderate

Total 15 8 7 47

the diagnosis was listed as “possible.” Essentially those patients with higher degrees of albumin in the urine were required to have less marked hypertension.

RESULTS

Using these criteria on the clinical records of the 229 cases of diabetes the diagnosis of intercapillary glomerulosclerosis was considered probable in twenty-six cases and possible in fifteen cases, a total of forty-one cases. After the selection had been made on clinical grounds alone, the autopsy protocols and microscopic sections listed as intercapillary glomerulo- sclerosis were reviewed and the clinical results correlated with the autopsy findings to evaluate our diagnostic accuracy.

Of the twenty-six cases considered as probable instances of intercapillary glomerulosclerosis twenty were subsequently shown to have ana- tomic lesions. The remaining six cases proved not to have intercapillary glomerulosclerosis. Five of these six cases had 3 to 4 plus albumi- nuria, minimal to marked hypertension and

dependent edema. The remaining case had generalized edema and only 2 plus albuminuria.

In the whole group of 229 cases of diabetes mellitus the pathologic records revealed that sixty-six had a specific lesion diagnosed as nodular intercapillary glomerulosclerosis; yet clinically only twenty cases were considered as probably having the syndrome and an addi- tional eight as possibly belonging in this cate- gory. In other words, a total of only twenty- eight cases of a possible sixty-six were correctly selected on the basis of having diabetes mellitus, at least 3 to 4 plus albuminuria, some edema usually of the dependent type and some hyper- tension. It is apparent that thirty-eight of the anatomically established cases did not present these findings. The results are summarized in Table II.

COMMENTS

Of the twenty-six cases considered as probable instances of intercapillary glomerulosclerosis only twenty proved to have this lesion, a false positive error of 24 per cent. In the less well defined “possible” category seven of the fifteen selected cases proved not to have anatomic lesions, an error of 47 per cent.

Taken together, thirteen cases later proven not to have intercapillary glomerulosclerosis appeared to present clinical findings indicative of this entity, an over-all false positive error of 32 per cent. It is of interest to note that the slight relaxation of the clinical requisites be- tween the “possible” and “probable” groups increased the diagnostic error from 24 to 47 per cent. This specifically refers to the dropping of the requisite, “edema.”

From the other viewpoint thirty-eight ana- tomically proven cases were not correctly identified in the clinical review. These cases represent 57 per cent of the total number of instances of intercapillary glomerulosclerosis. It is worthy of note that the 57 per cent error of cases not identified as intercapillary glomer- ulosclerosis is significantly higher than the 32 per cent error of those cases incorrectly called intercapillary glomerulosclerosis. This suggests that the syndrome may be more fre- quently missed than misdiagnosed.

It is, of course, obvious from the aforemen- tioned results that no well defined clinical syn- drome of intercapillary glomerulosclerosis exists even in the required presence of diabetes mellitus. The associated findings of albuminuria,

AMERICAN JOURNAL OF MEDICINE

Intercapillary Glomerulosclerosis, I -Rogers, Robbins 69’ edema and hypertension in an older age group of patients proven to have vascular degenerative disease produce no distinctive pattern per- mitting accurate clinical selection.

The so-called nephrotic picture was encoun- tered only four times and in one instance the patient subsequently proved not to have inter- capillary glomerulosclerosis.

CONCLUSIONS

The clinical records of 229 diabetics were evaluated on strictly clinical grounds as to the “possible” or “probable” presence of inter- capillary glomerulosclerosis. The clinical diag- noses were then correlated with the autopsy records. Of the forty-one cases selected clinically as having intercapillary glomerulosclerosis only twenty-eight proved to have the anatomic lesion, a false positive error of 32 per cent. Thirty- eight anatomic instances of the lesion were not selected because no apparent diagnostic clinical features were present; hence of a possible sixty- six cases only 43 per cent (twenty-eight) were correctly identified. No clear-cut clinical syn- drome, even in the presence of diabetes mellitus, can be said to exist and a diabetic not having this anatomic lesion may present the so-called classic features of intercapillary glomerulosclerosis.

An analysis of a large series of proven cases of intercapillary glomerulosclerosis, to be pre- sented in Part II, is needed to ascertain which of the so-called classic clinical features has the greatest differential significance and to deter- mine whether any additional clinical findings have value in more clearly defining this entity clinically.

REFERENCES

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2. PORTER, W. B. and WALKER, H. The clinical syn- drome associated with intercapillary glomerulo- sclerosis. 3. A. M. A., 116: 459, 1941.

3. SIEGAL, S. and ALLEN, A. C. Intercapillary glomer- ulosclerosis (Kimmelstiel-Wilson) and the ne- phrotic syndrome in diabetes mellitus. Am. j’. M. SC., 201: 516, 1941.

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NEWBURGER, R. A. and PETERS, J. P. Intercapillary glomerulosclerosis; a syndrome of diabetes, hyper- tension and albuminuria. Arch. Znt. Med., 64: 1252, 1939.

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BELL, E. F. Renal lesions in diabetes mellitus. rim. 3. Path., 18: 744, 1942.

LEFEBER, E. J. and DECHARD, G. M., JR. Nephrotic edema in diabetes mellitus. 7exn.r Statp ,f. Med., 41: 506, 1946.

16. RIFKIN, H., PARICER, J. G., POLIN, E. B., BERKMAN, J. I. and SPIRO, D. Diabetic glomerulosclerosis. Medicine, 27: 429, 1948.

17. MANN, G. V., GARDNER, C. and ROOT, H. F. Clin- ical manifestations of intercapillary glomerulo- sclerosis in diabetes mellitus. Am. 3. Med., 7: 3, 1949.

18. ROGERS, J., ROBBINS, S. 1,. andJEGIiERS, H. (Part II.)

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