Biological functions

• transport– albumin– transferin– ceruloplasmin– haptoglobin

• oncotic pressure regulation• coagulation• immunity

HypoproteinemiaHypoproteinemia

• with hypoalbuminemiawith hypoalbuminemia

– impairment of liver functionimpairment of liver function

– protein lossprotein loss

– changes in ECFchanges in ECF

• without hypoalbuminemiawithout hypoalbuminemia

– severe immunoglobulin deficiencysevere immunoglobulin deficiency

HyperproteinemiaHyperproteinemia

• hypergammaglobulinemiahypergammaglobulinemia– polyclonalpolyclonal

chronic inflammationchronic inflammation chronic liver diseasechronic liver disease autoimmune diseasesautoimmune diseases

– monoclonal monoclonal • multiple myelomamultiple myeloma• Waldenstrom`s macroglobulinemiaWaldenstrom`s macroglobulinemia• heavy-chains diseaseheavy-chains disease

• dehydrationdehydration

Methods of separation

• SPE - serum protein electrophoresis

• IEP – immunoelectrophoresis• IFE – immunofixation

electophoresis

Immunoelecctrophoresis (IEP)

Immunofixation (IFE)

AlbuminAlbumin (migrates to the (migrates to the aanode) node)

-1 globulins-1 globulins -1 protease inhibitor (a-1 antitrypsin) -1 protease inhibitor (a-1 antitrypsin)

• **-1 glycoprotein (* orosomucoid)-1 glycoprotein (* orosomucoid) fetoprotein (if present) fetoprotein (if present)

• high density lipoprotein (HDL) high density lipoprotein (HDL)

-2 globulins-2 globulins -2 macroglobulin -2 macroglobulin

• antithrombin III antithrombin III

• ceruloplasmin ceruloplasmin

• haptoglobin (this is usually the predominant component)haptoglobin (this is usually the predominant component)

Beta globulinsBeta globulins

• beta and pre-beta lipoproteins (LDL and VLDL) beta and pre-beta lipoproteins (LDL and VLDL)

• C3 C3

• C-reactive protein C-reactive protein

• hemoglobin (free) hemoglobin (free)

• plasminogen plasminogen

• transferrin (*"principal component of the beta1 subdivision") transferrin (*"principal component of the beta1 subdivision")

Gamma globulinsGamma globulins

• ImmunoglobulinsImmunoglobulins

Acute phase response (APR)

• positive APR• negative APR

beta - gamma (IgA) junction

Multiple myeloma

• B cell proliferation• monoclonal protein, Bence-Jones

proteinuria• anemia, leukopenia, low platelet count• hypercalcemia• „myeloma kidney”• increased viscosity TP, ESR• SPE, IEP, quantitating serum Ig

Heavy chain disease

• lymphocytic cell proliferation• only heavy chain production

Benign monoclonal gammopathyBenign monoclonal gammopathy

• "monoclonal gammapathy of "monoclonal gammapathy of uncertain significance" uncertain significance"

• "MGUS”"MGUS”• paraprotein < 2.0 gm/dL, Bence-paraprotein < 2.0 gm/dL, Bence-

Jones protein (rarely present) < 60 Jones protein (rarely present) < 60 mg/Lmg/L

Benign monoclonal gammopathyBenign monoclonal gammopathy

Case 1• A 66-year-old man presented with

sharp, constant, low back pain, dating from a fall from a ladder 6 weeks earlier. On direct questioning, he did admit to vague malaise for over 6 months. On examination, he was in considerable pain but otherwise seemed fairly fit.

• He was mildly anaemic but had no lymphadenopathy and no fever. There were no signs of bruising, no finger clubbing, no hepatosplenomegaly and no abdominal masses

Case 1

• On investigation, his haemoglobin was low (102g/l) due to fewer red cells but his white-cell count was normal (6.2 x 109/l). He had a normal differential white-cell count and a normal platelet count but his ESR was 98mm/h.

• Total serum proteins were raised at 98g/l (NR 65-75g/l)

Case 1• His serum albumin, creatinine and

urea were normal. • He had a raised serum calcium level

(3.2mmol/l) but a normal alkaline phosphatase.

• Serum protein electrophoresis revealed a monoclonal band in the gamma region, with considerable immunosuppression of the rest of this region.

• The band was typed by immunoelectrophoresis and shown to be IgG of kappa type.

• Quantitation of serum immunoglobulins showed a raised IgG of 67g/l (NR 7.2-19.0g/l), a low IgA of 0.3g/l (NR 0.8-5.0g/l), and a low IgM of 0.2g/l (NR 0.5-2.0g/l).

• Electrophoretic examination of concentrated urine showed a monoclonal band in the beta region. On immunoelectrophoresis, this band was composed of free kappa light chains.

• X-rays of his back showed a small, punched-out lesion in the second lumbar vertebra

Case

• Bone marrow examination showed an increased number of atypical plasma cells; these constituted 45% of the nucleated cells found on the film. This man showed the features required for a diagnosis of multiple myeloma

Case

• A 49-year-old woman presented with a 6-month history of vague aches and pains in her chest. On examination, she was overweight but had no abnormal physical signs.

Case 2

• Her haemoglobin was 136g/l with a white-cell count of 6.7 x 109/l and a normal differential.

• Her ESR was 34mm/h. • Tests of thyroid function were

normal.

Case 2• However, protein electrophoresis

showed a small paraprotein band in the gamma region; this band was an IgG of lambda type.

• Her serum IgG was raised at 20.1g/l (NR 7.2-19.0g/l),

• with an IgA of 1.9g/l (NR 0.8-5.0g/l) and an IgM of 3.0g/l (NR 0.5-3.0g/l).

• electrophoresis of concentrated urine showed no proteinuria. The paraprotein measured 10g/l by densitometry.

• A bone marrow examination showed only 12% plasma cells.

Case 2• the absence of

– osteolytic lesions, – monoclonal free light chains in the urine

• normal serum IgA and IgM levels, • these findings supported a diagnosis of

benign monoclonal gammopathy, also known as a monoclonal gammopathy of unknown significance (MGUS)

• This woman has been followed at 6-monthly intervals for 3 years with no change in the paraprotein level, and the urine remains free of monoclonal light chains. She will continue to be seen at yearly intervals.