- Email: [email protected]
ALTERNATE-DAY IMMUNOSUPPRESSION
267
histologically confirmed. Two patients had had recurrence of a previous graft 2 years earlier, while being treated with azathioprine. One patient lost his graft within 5 months after transplantation, while the other five still have a normal serum creatinine 1-2 -5 years after transplantation. Recurrence of glomerulonephritis in kidney allografts during conventional immunosuppression by azathioprine is well known.44 Our results demonstrate that this occurs also during immunosuppression with cyclosporin. Claims that this drug holds promise for the treatment of several forms of glomerulonephritis should therefore be viewed with scepticism until formal proof is provided by controlled trials. was
FGS in
Division of St Radboud
Nephrology,
A.
Hospital, University of Nijmegen, 6500HB Nijmegen, Netherlands
J. VOETS
A. J. HOITSMA R.A.P. KOENE
1. Cattran DC, Dossetor J, Halloran PF, et al. Ciclosporin in glomerulonephritis: a pilot study. In: Schindler R, ed. Ciclosporin in auto-immune disease. Heidelberg: Springer, 1985: 311-15. 2. Meyrier A, Simon P, Perret G, Condamin-Meyrier MC. Use of ciclosporin in idiopathic corticoresistant or corticodependent nephrotic syndrome (minimal change glomerulopathy and focal-segmental hyalinosis). In: Schindler R, ed. Ciclosporin in autoimmune disease. Heidelberg: Springer, 1985: 316-22. 3. Brodehl J, Hoyer PF. Ciclosporin treatment of idiopathic nephrotic syndrome in children (minimal change disease and focal segmental glomerulonephritis). In: Schindler R, ed. Ciclosporin in autoimmune disease. Heidelberg: Springer, 1985: 329-33. 4. Morzycka M, Croker BP Jr, Seigler HF, et al. Evaluation of recurrent glomerulonephritis in kidney allografts. Am J Med 1982; 72: 588-98.
HLA MATCHING AND CYCLOSPORIN IMMUNOSUPPRESSION: A STRONG CORRELATION
cyclosporin showed that there was a 26% difference in one-year graft survival for transplants with the best (zero) A,B,DR mismatch as compared with the worst (six) mismatches. Thus, the HLA matching effect was larger than the cyclosporin effect among patients treated with cyclosporin. Even among patients who did not receive cyclosporin, the difference in the best A,B,DR mismatch and the worst mismatch was 30% at one year. Most of the previous studies on HLA matching have been based on the effect of the A,B locus alone or, more recently, the DR locus. It now seems that if all these loci are combined, a much higher degree of correlation between matching and graft survival is obtained.6 Mickey et als have calculated that, with a recipient pool of 10 000, as many as 28% of the transplants can be done with zero A,B,DR mismatches. Hence, despite the difficulty in matching for three highly polymorphic HLA loci, with sufficient cooperation among transplant centres high degrees of compatibility can be achieved. The often expressed notion that, with the advent of cyclosporin, HLA matching can be ignored, has not been substantiated. Data from the multicentre European trial6 of cyclosporin shows that there is a loss of grafts even after 3 years. This late loss is probably attributable to underlying incompatibility. With
improving one-year success rates, long-lasting transplants can now sought by utilising zero mismatched HLA A,B,DR grafts.
be
UCLA Tissue Typing Laboratory, UCLA School of Medicine, Los Angeles, California 90024, USA
1. Harris
JAMES CICCIARELLI PAUL I. TERASAKI M. RAY MICKEY
et al. Azathioprine and cyclosporin: different matching criteria needed? Lancet 1985; ii: 802-04. 2. Opelz G. Ninth International Histocompatibility Workshop renal transplant study. In: Albert E, Baur MP, Mayr WR, eds. Histocompatibility 1984. Heidelberg: Springer, 1984: 342-47. 3. Cats S, Terasaki P, Perdue S, Mickey MR. Effect of HLA typing and transfusions on cyclosporin-treated renal allograft recipients. N Engl J Med 1984; 311: 675-76. 4. Opelz G. Effect of HLA matching, blood transfusion and presentation in cyclosporintreated kidney transplant recipients. Transplant Proc 1985; 17: 2179-83 5. Mickey MR, Carnahan B, Terasaki P. Effectiveness of zero A,B,DR mismatch for cadaver kidneys. Transplant Proc 1985; 17: 2222-24. 6. Calne R, Wood AM. Cyclosporin in cadaveric renal transplantation: 3 year follow-up of a European multicentre trial. Lancet 1985; ii: 549.
K, Gosling DC, Campbell MJ,
tissue
SIR,-The inverse effect of HLA matching in cyclosporin-treated patients reported from the UK by the Wessex transplantation centre! is likely to be an unusual finding at a single unit. Studies based on data from several centres reveal a clear beneficial effect of HLA matching in cyclosporin-treated patients. 2-5 From data kindly provided to us by more than a hundred transplant centres in the US and Canada, we have re-examined the interrelation. The relative effect of HLA matching and cyclosporin can be separated, as shown in the figure. The improvement in one-year graft survival ranged from 6% to 17% for zero to five HLA A,B,DR mismatched antigens. This means that graft survival was already high without cyclosporin for well-matched transplants whereas with poorly matched grafts, cyclosporin produced a much greater degree of improvement. Cyclosporin-treated patients can be seen to have a 12% higher oneyear graft survival rate. The same data for patients treated with
ALTERNATE-DAY IMMUNOSUPPRESSION
SiR,—Professor Salaman and Mr Griffin (Nov 9, p 1066) report
immunosuppression with a combination of cyclosporin, azathioprine, and prednisolone may be unsafe. We have recommended alternate-day cyclosporin and azathioprine plus steroids, describing our experience in five patients,’ and have since investigated this regimen in dogs. Kidneys were transplanted to the iliac vessels between unrelated mongrel dogs of either sex and the opposite kidney was removed. Serum creatinine measurements and blood cell counts were made at least weekly. Full post-mortem that
examinations were done on animals that died or were killed because
Effects of cyclosporin and HLA matching
on
one-year graft survival.
Cross-hatched area on left represents difference in cyclosporin and noncyclosporin between specific mismatching categories. Stippled area on right shows difference in cyclosporin-treated patients with 1, 2, 3, 4, 5, and 6 mismatched antigen categories as compared with zero mismatch ideal; crosshatched area is same comparison in non-cyclosporin-treated patients.
they appeared ill, and an open biopsy was done on day 84 on all surviving animals. Group 1 (alternate day) animals received either cyclosporin 25 mg/kg or azathioprine 5 mg/kg on alternate days. Group 2 (halfdose daily) animals received cyclosporin 12 -5 mg/kg and azathioprine 2’55 mg/kg every day. Drugs were administered parenterally and then orally after day 3. The results are shown in the table and figure. Survival at 84 days in group 1 was 67%, and biopsy of the 8 survivors revealed no evidence of rejection or cyclosporin nephrotoxicity in 6, rejection in 1, and proximal tubular vacuolation indicating cyclosporin toxicity in 1. In group 2 survival at 84 days was 36%, in the 5 survivors there was no evidence of rejection or cyclosporin toxicity in 3 but in 1 rejection was seen and another had cyclosporin toxicity (proximal tubular vacuolation) and severe thrombocytopenia and leucopenia. The serum creatinine of the survivors in group 1 was higher than that of survivors in group 2, but remained within the normal range except in 1 animal with biopsy evidence of rejection.
268 MICROALBUTEST AND
SURVIVAL OF DOG KIDNEY ALLOGRAFTS
*Relection, tPapilloma &
hypoplasia,
cellulitis, :j:Pulmonary embolus, §Septicaemia, "Marrow
**Pneumonia.
RIA VALUES
We stand by our previous conclusion that this method seems accurate enough for routine patient diabetic unit.
rapid bedside screening in a
INSERM Biomathematics Research Unit, Paris
D. COSTAGLIOLA
INSERM Statistical Research Unit, Villejuif
A. FONTBONNE
Department of Diabetes, Hôtel-Dieu Hospital, 75181
M. LETANOUX G. SLAMA
Paris, France
1. Hutchison ii
AS, O’Reilly D St J. Bedside estimation of microalbuminuria. Lancet 1985,
44.
2. Slama
G, Boillot J, Desplanque N, Letanoux M Bedside estimation of microalbuminLancet 1985; i: 1338.
uria.
Survival rates in dogs on one of two after kidney transplantation.
immunosuppressive regimens
Although the total amount of immunosuppressive agents received by each animal over the study period was the same it is clear that the mode of administration is important. Animals given half dose daily of both drugs were more prone to overwhelming infections (2) or marrow hypoplasia (3), this becoming apparent in the last 4 weeks of the study. The findings of Salaman and Griffin that combinations of immunosuppressive agents given daily lead to overimmunosuppression with subsequent complications is supported by this study. Our experimental work supports our proposal that alternate-day therapy may have significant advantages, particularly in patients with complications from standard immunosuppressive regimens. Department of Surgery, University of Cambridge Clinical School,
Addenbrooke’s Hospital, Cambridge CB2 2QQ
ST J. COLLIER
R. Y. CALNE
M. THICK M. DE CURTINS D. J. G. WHITE
N. V. JAMIESON E. BARROSO S. THIRU
1. Calne RY, Collier DStJ, Evans DB. Alternate steroids. Lancet 1985; ii: 1448.
SIR,-An increased urinary albumin excretion
rate
short of
clinical
day cyclosporin and azathioprine plus
BEDSIDE ESTIMATION OF MICROALBUMINURIA
Sin,—Hutchison and O’Reillyl calculated from our data2the 95% range of albuminuria values obtained by radioimmunoassay (RIA) on the assumption that RIA values are normally distributed. They are not. Hutchison and O’Reilly give the standard deviation, for a mean of 7 g/ml, as ±53 /-lg/ml, so the distribution is clearly skewed. The 95% range observed for RIA (see table) proves that their conclusion about the predictive power of the ’Microalbutest’ is wrong. A microalbutest value of 30 (g/ml or less is equivalent to less than 46 /-lg/ml by RIA, not 100 /-lg/ml as claimed by Hutchison and O’Reilly. Furthermore a microalbutest value ofless than 20 /-lg/ml is equivalent to less than 26 g/ml by the RIA method. We agree that our definitions of specificity and sensitivity were not clearly explained, but if we follow Hutchison and O’Reilly and calculate them with the RIA method as a reference and with cut-off values of 30 /-lg/ml for both methods, we arrive at a specificity of 97-8% and a sensitivity of 89’ 7%; with cut-offs at 20 /-lg/ml these figures are 98, 2alo and 81 . 2%, respectively.
proteinuria (microalbuminuria) seems to be a strong and early predictor of clinical nephropathy in patients with insulindependent diabetes mellitus.I-3 An overnight urinary albumin excretion rate of 30-200 g/min, a range that identifies diabetic patients at risk, corresponds to a urinary albumin concentration of about 25-170 mg/1, which cannot be detected by tests such as ’Albustix’. Since microalbuminuria can sometimes be reversed by strict blood glucose contro14 a simple method for detecting microalbuminuria is needed. We have evaluated the’Microalbutest’
(Ames Division, We studied 59
Miles
Laboratories). insulin-dependent diabetic patients aged
5-36 years ago, and selected to albuminuria from 1 - 3 to 415 mg/1. 5 patients had
years,
diagnosed
cover a
16-60 range of
positive albustix The first morning urine sample was tested by microalbutest, a sensitised tablet form of albustix based on the protein error of indicators and making use of buffered bromophenol-blue in an alkali macerated cellulose matrix. One drop of urine (60 1) was put on the centre of a tablet and allowed to soak in (this takes about 5 s). One drop of distilled water was added, followed by a second drop after absorption of the first. The test reading was compared with a negative control with a urinary albumin of 10 mg/l. A blue-green colour constituted a positive result. Samples were tested and read by two observers who were blind to the albumin concentration measured by radioimmunoassay (RIA).5 Total urinary protein was measured colonmetrically. Semiquantitation was attempted by grading colour
tests.
intensity. We estimated sensitivity (proportion of samples with RIA albumin of 25 mg/1 or more correctly identified), specificity (proportion with albumin below 25 mg/l correctly identified), and predictive value (proportion of test positives with albumin 25 mg/l or
more).
The two observers agreed on 56 of the 59 paired tests (95%). The 3 discordant tests were resolved by a third party before statistical
analysis. The sensitivity of the microalbutest was 8807o and the specificity was 91% (see figure). The predictive value of a positive test was 94%. There was a significant relation (r = 0 - 77, p<0 001) between urinary albumin and total protein. The total protein in 3 of the 4 samples reading falsely negative by microalbutest was low (16-7—24-88 mg/dl). Total protein in 1 specimen reading falsely positive by microalbutest was high (45 - 8 mg/dl).
histologically confirmed. Two patients had had recurrence of a previous graft 2 years earlier, while being treated with azathioprine. One patient lost his graft within 5 months after transplantation, while the other five still have a normal serum creatinine 1-2 -5 years after transplantation. Recurrence of glomerulonephritis in kidney allografts during conventional immunosuppression by azathioprine is well known.44 Our results demonstrate that this occurs also during immunosuppression with cyclosporin. Claims that this drug holds promise for the treatment of several forms of glomerulonephritis should therefore be viewed with scepticism until formal proof is provided by controlled trials. was
FGS in
Division of St Radboud
Nephrology,
A.
Hospital, University of Nijmegen, 6500HB Nijmegen, Netherlands
J. VOETS
A. J. HOITSMA R.A.P. KOENE
1. Cattran DC, Dossetor J, Halloran PF, et al. Ciclosporin in glomerulonephritis: a pilot study. In: Schindler R, ed. Ciclosporin in auto-immune disease. Heidelberg: Springer, 1985: 311-15. 2. Meyrier A, Simon P, Perret G, Condamin-Meyrier MC. Use of ciclosporin in idiopathic corticoresistant or corticodependent nephrotic syndrome (minimal change glomerulopathy and focal-segmental hyalinosis). In: Schindler R, ed. Ciclosporin in autoimmune disease. Heidelberg: Springer, 1985: 316-22. 3. Brodehl J, Hoyer PF. Ciclosporin treatment of idiopathic nephrotic syndrome in children (minimal change disease and focal segmental glomerulonephritis). In: Schindler R, ed. Ciclosporin in autoimmune disease. Heidelberg: Springer, 1985: 329-33. 4. Morzycka M, Croker BP Jr, Seigler HF, et al. Evaluation of recurrent glomerulonephritis in kidney allografts. Am J Med 1982; 72: 588-98.
HLA MATCHING AND CYCLOSPORIN IMMUNOSUPPRESSION: A STRONG CORRELATION
cyclosporin showed that there was a 26% difference in one-year graft survival for transplants with the best (zero) A,B,DR mismatch as compared with the worst (six) mismatches. Thus, the HLA matching effect was larger than the cyclosporin effect among patients treated with cyclosporin. Even among patients who did not receive cyclosporin, the difference in the best A,B,DR mismatch and the worst mismatch was 30% at one year. Most of the previous studies on HLA matching have been based on the effect of the A,B locus alone or, more recently, the DR locus. It now seems that if all these loci are combined, a much higher degree of correlation between matching and graft survival is obtained.6 Mickey et als have calculated that, with a recipient pool of 10 000, as many as 28% of the transplants can be done with zero A,B,DR mismatches. Hence, despite the difficulty in matching for three highly polymorphic HLA loci, with sufficient cooperation among transplant centres high degrees of compatibility can be achieved. The often expressed notion that, with the advent of cyclosporin, HLA matching can be ignored, has not been substantiated. Data from the multicentre European trial6 of cyclosporin shows that there is a loss of grafts even after 3 years. This late loss is probably attributable to underlying incompatibility. With
improving one-year success rates, long-lasting transplants can now sought by utilising zero mismatched HLA A,B,DR grafts.
be
UCLA Tissue Typing Laboratory, UCLA School of Medicine, Los Angeles, California 90024, USA
1. Harris
JAMES CICCIARELLI PAUL I. TERASAKI M. RAY MICKEY
et al. Azathioprine and cyclosporin: different matching criteria needed? Lancet 1985; ii: 802-04. 2. Opelz G. Ninth International Histocompatibility Workshop renal transplant study. In: Albert E, Baur MP, Mayr WR, eds. Histocompatibility 1984. Heidelberg: Springer, 1984: 342-47. 3. Cats S, Terasaki P, Perdue S, Mickey MR. Effect of HLA typing and transfusions on cyclosporin-treated renal allograft recipients. N Engl J Med 1984; 311: 675-76. 4. Opelz G. Effect of HLA matching, blood transfusion and presentation in cyclosporintreated kidney transplant recipients. Transplant Proc 1985; 17: 2179-83 5. Mickey MR, Carnahan B, Terasaki P. Effectiveness of zero A,B,DR mismatch for cadaver kidneys. Transplant Proc 1985; 17: 2222-24. 6. Calne R, Wood AM. Cyclosporin in cadaveric renal transplantation: 3 year follow-up of a European multicentre trial. Lancet 1985; ii: 549.
K, Gosling DC, Campbell MJ,
tissue
SIR,-The inverse effect of HLA matching in cyclosporin-treated patients reported from the UK by the Wessex transplantation centre! is likely to be an unusual finding at a single unit. Studies based on data from several centres reveal a clear beneficial effect of HLA matching in cyclosporin-treated patients. 2-5 From data kindly provided to us by more than a hundred transplant centres in the US and Canada, we have re-examined the interrelation. The relative effect of HLA matching and cyclosporin can be separated, as shown in the figure. The improvement in one-year graft survival ranged from 6% to 17% for zero to five HLA A,B,DR mismatched antigens. This means that graft survival was already high without cyclosporin for well-matched transplants whereas with poorly matched grafts, cyclosporin produced a much greater degree of improvement. Cyclosporin-treated patients can be seen to have a 12% higher oneyear graft survival rate. The same data for patients treated with
ALTERNATE-DAY IMMUNOSUPPRESSION
SiR,—Professor Salaman and Mr Griffin (Nov 9, p 1066) report
immunosuppression with a combination of cyclosporin, azathioprine, and prednisolone may be unsafe. We have recommended alternate-day cyclosporin and azathioprine plus steroids, describing our experience in five patients,’ and have since investigated this regimen in dogs. Kidneys were transplanted to the iliac vessels between unrelated mongrel dogs of either sex and the opposite kidney was removed. Serum creatinine measurements and blood cell counts were made at least weekly. Full post-mortem that
examinations were done on animals that died or were killed because
Effects of cyclosporin and HLA matching
on
one-year graft survival.
Cross-hatched area on left represents difference in cyclosporin and noncyclosporin between specific mismatching categories. Stippled area on right shows difference in cyclosporin-treated patients with 1, 2, 3, 4, 5, and 6 mismatched antigen categories as compared with zero mismatch ideal; crosshatched area is same comparison in non-cyclosporin-treated patients.
they appeared ill, and an open biopsy was done on day 84 on all surviving animals. Group 1 (alternate day) animals received either cyclosporin 25 mg/kg or azathioprine 5 mg/kg on alternate days. Group 2 (halfdose daily) animals received cyclosporin 12 -5 mg/kg and azathioprine 2’55 mg/kg every day. Drugs were administered parenterally and then orally after day 3. The results are shown in the table and figure. Survival at 84 days in group 1 was 67%, and biopsy of the 8 survivors revealed no evidence of rejection or cyclosporin nephrotoxicity in 6, rejection in 1, and proximal tubular vacuolation indicating cyclosporin toxicity in 1. In group 2 survival at 84 days was 36%, in the 5 survivors there was no evidence of rejection or cyclosporin toxicity in 3 but in 1 rejection was seen and another had cyclosporin toxicity (proximal tubular vacuolation) and severe thrombocytopenia and leucopenia. The serum creatinine of the survivors in group 1 was higher than that of survivors in group 2, but remained within the normal range except in 1 animal with biopsy evidence of rejection.
268 MICROALBUTEST AND
SURVIVAL OF DOG KIDNEY ALLOGRAFTS
*Relection, tPapilloma &
hypoplasia,
cellulitis, :j:Pulmonary embolus, §Septicaemia, "Marrow
**Pneumonia.
RIA VALUES
We stand by our previous conclusion that this method seems accurate enough for routine patient diabetic unit.
rapid bedside screening in a
INSERM Biomathematics Research Unit, Paris
D. COSTAGLIOLA
INSERM Statistical Research Unit, Villejuif
A. FONTBONNE
Department of Diabetes, Hôtel-Dieu Hospital, 75181
M. LETANOUX G. SLAMA
Paris, France
1. Hutchison ii
AS, O’Reilly D St J. Bedside estimation of microalbuminuria. Lancet 1985,
44.
2. Slama
G, Boillot J, Desplanque N, Letanoux M Bedside estimation of microalbuminLancet 1985; i: 1338.
uria.
Survival rates in dogs on one of two after kidney transplantation.
immunosuppressive regimens
Although the total amount of immunosuppressive agents received by each animal over the study period was the same it is clear that the mode of administration is important. Animals given half dose daily of both drugs were more prone to overwhelming infections (2) or marrow hypoplasia (3), this becoming apparent in the last 4 weeks of the study. The findings of Salaman and Griffin that combinations of immunosuppressive agents given daily lead to overimmunosuppression with subsequent complications is supported by this study. Our experimental work supports our proposal that alternate-day therapy may have significant advantages, particularly in patients with complications from standard immunosuppressive regimens. Department of Surgery, University of Cambridge Clinical School,
Addenbrooke’s Hospital, Cambridge CB2 2QQ
ST J. COLLIER
R. Y. CALNE
M. THICK M. DE CURTINS D. J. G. WHITE
N. V. JAMIESON E. BARROSO S. THIRU
1. Calne RY, Collier DStJ, Evans DB. Alternate steroids. Lancet 1985; ii: 1448.
SIR,-An increased urinary albumin excretion
rate
short of
clinical
day cyclosporin and azathioprine plus
BEDSIDE ESTIMATION OF MICROALBUMINURIA
Sin,—Hutchison and O’Reillyl calculated from our data2the 95% range of albuminuria values obtained by radioimmunoassay (RIA) on the assumption that RIA values are normally distributed. They are not. Hutchison and O’Reilly give the standard deviation, for a mean of 7 g/ml, as ±53 /-lg/ml, so the distribution is clearly skewed. The 95% range observed for RIA (see table) proves that their conclusion about the predictive power of the ’Microalbutest’ is wrong. A microalbutest value of 30 (g/ml or less is equivalent to less than 46 /-lg/ml by RIA, not 100 /-lg/ml as claimed by Hutchison and O’Reilly. Furthermore a microalbutest value ofless than 20 /-lg/ml is equivalent to less than 26 g/ml by the RIA method. We agree that our definitions of specificity and sensitivity were not clearly explained, but if we follow Hutchison and O’Reilly and calculate them with the RIA method as a reference and with cut-off values of 30 /-lg/ml for both methods, we arrive at a specificity of 97-8% and a sensitivity of 89’ 7%; with cut-offs at 20 /-lg/ml these figures are 98, 2alo and 81 . 2%, respectively.
proteinuria (microalbuminuria) seems to be a strong and early predictor of clinical nephropathy in patients with insulindependent diabetes mellitus.I-3 An overnight urinary albumin excretion rate of 30-200 g/min, a range that identifies diabetic patients at risk, corresponds to a urinary albumin concentration of about 25-170 mg/1, which cannot be detected by tests such as ’Albustix’. Since microalbuminuria can sometimes be reversed by strict blood glucose contro14 a simple method for detecting microalbuminuria is needed. We have evaluated the’Microalbutest’
(Ames Division, We studied 59
Miles
Laboratories). insulin-dependent diabetic patients aged
5-36 years ago, and selected to albuminuria from 1 - 3 to 415 mg/1. 5 patients had
years,
diagnosed
cover a
16-60 range of
positive albustix The first morning urine sample was tested by microalbutest, a sensitised tablet form of albustix based on the protein error of indicators and making use of buffered bromophenol-blue in an alkali macerated cellulose matrix. One drop of urine (60 1) was put on the centre of a tablet and allowed to soak in (this takes about 5 s). One drop of distilled water was added, followed by a second drop after absorption of the first. The test reading was compared with a negative control with a urinary albumin of 10 mg/l. A blue-green colour constituted a positive result. Samples were tested and read by two observers who were blind to the albumin concentration measured by radioimmunoassay (RIA).5 Total urinary protein was measured colonmetrically. Semiquantitation was attempted by grading colour
tests.
intensity. We estimated sensitivity (proportion of samples with RIA albumin of 25 mg/1 or more correctly identified), specificity (proportion with albumin below 25 mg/l correctly identified), and predictive value (proportion of test positives with albumin 25 mg/l or
more).
The two observers agreed on 56 of the 59 paired tests (95%). The 3 discordant tests were resolved by a third party before statistical
analysis. The sensitivity of the microalbutest was 8807o and the specificity was 91% (see figure). The predictive value of a positive test was 94%. There was a significant relation (r = 0 - 77, p<0 001) between urinary albumin and total protein. The total protein in 3 of the 4 samples reading falsely negative by microalbutest was low (16-7—24-88 mg/dl). Total protein in 1 specimen reading falsely positive by microalbutest was high (45 - 8 mg/dl).