Paul Kimmelstiel

The pathologist Paul Kimmelstiel (1900-1970) is remembered with Clifford Wilson (1906-1997) for their description of the characteristic diabetic kidney disease intercapillary glomerulosclerosis. Kimmelstiel was born in Hamburg and did his training while German medicine was still in its heyday. He studied at no less than five of the great universities -- Keil, Munich, Hamburg, Bonn and Tübingen, receiving his medical degree from the latter in 1923. Eventually he became first assistant in Hamburg under Theodor Fahr (1877-1945), the leading kidney pathologist of the time. In 1934, because of Nazi oppression, he emigrated to the Mallory Institute at Boston City Hospital.

Clifford Wilson completed his junior medical training at the London hospital in 1934 and was awarded a Rockefeller travelling fellowship to Harvard where, for a young man, he turned out to be in the right place at the right time and achieved eponymous fame. The histological feature which Kimmelstiel and Wilson described was very characteristic with the noteworthy feature being large hyaline nodules in the glomeruli. When commenting on the clinical picture they noted that:

On reviewing the clinical data, it was surprising to find a previous history of diabetes in all of these cases, with the exception of one... A second striking feature was severe and widespread oedema. The clinical picture appears in fact to be almost as characteristic as the histological one: the patients are relatively old; hypertension is present, usually of the benign type, and kidneys frequently shows signs of decompensation; there is a history of diabetes, usually of long-standing; the presenting symptoms may be those of oedema of the nephrotic type, renal decompensation or heart failure; the urine contains large amounts of albumin and there is usually impairment of concentrating power with or without nitrogen retention.

For the patient who did not apparently have diabetes [case 2] the only details are ‘H.G., male, aged 60 years, was admitted in extremis complaining of pain in the chest and cough’. However, like the others he had generalised oedema. The oedema was said to be out of all proportion to cardiac failure and ‘may be extreme when no signs of heart failure can be demonstrated’. Presumably this meant that Clifford Wilson had examined some of the patients antemortem, although most died within a few hours of admission. Their mean age was 57 and the longest history of diabetes 15 years. No details of diabetic treatment were given.

This paper has now become a classic but it led to considerable confusion in the next 15 years when, according to one writer, the ‘Kimmelstiel - Wilson syndrome came to mean all things to all men.’ In addition to the nodular lesion the eponym was used for a diffuse process involving the glomerulus, for the so-called ‘exudative lesion’ and even for the clinical picture of diabetic nephropathy. Three main points were at issue: (1) was the lesion specific for diabetes? (2) did it cause the clinical syndrome? and, (3) was the lesion inter-capillary? In retrospect the real importance of the paper was that it drew attention to a specific diabetic renal disease separate from atherosclerosis.

In 1942 Fahr reported the diffuse variety of diabetic glomerulosclerosis and this was first described in the English language literature in 1944 but not generally accepted as an essential and specific part of the diabetic lesion until the same changes were fully described by Elixious Thompson (‘Tommy’) Bell (1880-1963) in 1950.[1] Bell pointed out that nodules were always associated with diffuse lesions, diffuse lesions were often found alone, and diffuse lesions could progress to complete obliteration of the glomerulus without ever forming definite nodules. He thought nodules developed from the diffuse lesions and that it was impossible to make a clear distinction between the two. Bell suggested that the term ‘Kimmelstiel –Wilson’ lesion should be restricted to nodular inter-capillary glomerulosclerosis.

From 1940 to 1958 Kimmelstiel had to go back to general pathology to earn enough money to support his family. In 1958 he became professor of pathology in Milwaukee and over the next decade published 38 papers on renal pathology including ones on the glomerular basement membrane in diabetes. Clifford Wilson became professor of medicine at the London hospital in 1946 and his research was on the relationship between the kidneys and blood pressure.

References

  1. ^ Bell ET. Renal Diseases. 2nd edition. Philadelphia, Lea and Febiger,1950

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