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OBJECTIVESerum creatinine levels are lower in diabetic patients compared with their nondiabetic counterparts. Therefore, estimated glomerular filtration rate (eGFR) is higher in the former than in the latter group. Factors associated with overestimation of renal function in diabetic patients were examined, and new formulae reflecting precise eGFR were created. RESEARCH DESIGN AND METHODSEighty subjects (age 56.5 6 15.4 years; 35 males [43.8%]; 40 patients with diabetes and 40 nondiabetic subjects) were enrolled. GFR was evaluated by inulin clearance (C in ). eGFR values were calculated based on serum creatinine and/or serum cystatin C levels. The factors related to the dissociation between eGFR and C in in diabetic patients and the agreement among each of three eGFR and C in were compared. RESULTSAlthough C in was not significantly different between the diabetic and nondiabetic subjects (P = 0.2866), each of three eGFR measures from the diabetic patients was significantly higher than that of the nondiabetic subjects (P < 0.01). There were significant and positive correlations between the ratio of each eGFR/ C in , hemoglobin A 1c , and glycated albumin. The intraclass correlation coefficients in diabetic patients were weaker than those in the nondiabetic subjects, and the intercepts of the regression lines between each eGFR measure and C in in the diabetic patients were significantly higher than those of the nondiabetic subjects. New formulae for the calculation of eGFR corrected by the glycemic control indices were better than the original eGFR, particularly in diabetic patients. CONCLUSIONSeGFR overestimates C in as glycemic controls worsen. eGFR corrected by hemoglobin A 1c is considered to be clinically useful and feasible.

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Introduction A positive cross-match (+CMX) indicates the presence of donor-specific allo-antibodies (DSA) associated with a graft loss rate that exceeds 80%. Anti-ABO blood group antibodies develop in response to exposure to foreign blood groups, resulting in immediate graft loss. In the last decade, the field of ABO-incompatible kidney transplantation has achieved remarkable clinical success in Japan. However, previous reports have shown poor outcomes in patients with high pretreatment anti-A/B antibody titers. Although recent reports show successful kidney transplantation in the presence of DSA, it remains a medical challenge. A desensitization protocol in highly HLAsensitized and ABO-incompatible high titer kidney transplantation has not yet been established. Methods We treated 6 patients with high (>1:512) anti-A/B antibody titers and 2 highly HLA-sensitized patients. Our immunosuppressive protocol initiated 1 month prior to surgery included mycophenolate mofetil 1 g/day and/or low dose steroid (methylprednisolone 8mg/day). Two doses of the anti-CD20 antibody, rituximab (150mg/m2) were administered 2 weeks before and on the day of transplantation. We performed antibody removal with 6-12 sessions of plasmapheresis (plasma exchange or doublefiltration plasmapheresis) before transplantation. The number of DFPP and PE was determined by the baseline blood group antibody titer and panel-reactive antibody levels. The goal of DFPP and PE was to achieve a titer of ≤1:16 in ABO-incompatible transplantation and a negative T cell donor specific flow cytometric CXM in highly sensitized transplantation at the time of the transplant. If antibody titer remained above 1: 512 or a T cell donor specific flow cytometric CXM was positive after the eight sessions of DFPP or PE, kidney transplantation was postponed. Splenectomy was also performed on the day of transplantation. Postoperative immunosuppression followed the same regimen as ABO-compatible cases, in which calcineurin inhibitors were initiated 3 days before transplantation combined with 2 doses of basiliximab. Results Of the 8 patients, 7 subsequently underwent successful kidney transplantation. The one remaining patient with ABO incompatibility had an antibody blood group titer that was greater than 1: 512 in spite of the pre-transplant antibody removal with 8 sessions of plasmapheresis. She underwent only a splenectomy and currently receives administration of MMF 0.5g/day. However, she continues to demonstrate a high antibody titer (1:2048) at the time of this writing. We recorded 100% patient and graft survival rates in our recipients. Acute cellular rejection and acute antibody mediated rejection episodes occurred in 1 of the 7 who received transplants. Conclusions These findings suggest that our immunosuppressive regimen of rituximab infusions, splenectomy, plasmapheresis and pharmacologic immunosuppression may prove effective as a desensitization protocol in highly HLA-sensitized and ABO-incompatible high titer kidney transplantation.

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