This report considers the pathophysiologic significance of capillary basement-membrane thickening in diabetic nephropathy and retinopathy and the relationship of capillary basement-membrane thickening to increased susceptibility to infections and to increased vascular permeability in diabetes. The evidence available (1) indicates that basement-membrane thickening affects most if not all capillaries of the diabetic and may contribute to increased susceptibility to infection and (2) suggests that increased capillary permeability in diabetes need not be attributed to basement-membrane changes per se, but rather may be due to changes in the cellular elements of the capillary wall.

Studies of the microcirculation in diabetes in the last fifteen years have concentrated heavily on anatomic and biochemical abnormalities of the capillary basement membrane. Greater insights into basement membrane changes have eclipsed the previous picture of widespread progressive deterioration of the entire microcirculation. The history, variety of organ involvement, pattern of circulatory decline, and associated anatomic, physiologic, and biochemical findings are re-examined so that recently described potential mechanisms for the development of diabetic microangiopathy may be understood in a broader perspective. The possible contributions of seven categories of diabetic changes to damage of the microcirculation are outlined. The categories are: (1) altered basement membrane, (2) altered cellular function, (3) cell metabolic changes, (4) altered blood flow properties, (5) distrubed hemostasis, (6) altered oxygen transport, and (7) altered hormone production. The variety of clinical manifestations in long-standing diabetes related to microangiopathy appears to be due to a combination of a widely variable over-all rate of progression and a differing ability of body tissues and organs to accommodate to the sequential circulatory changes. The slow rate of deterioration in most diabetics suggests that several abnormalities must interact to produce the observed progression. A clear understanding of the interactions responsible for diabetic microangiopathy is becoming more important as new options in the management of diabetes become available.