Biological functions transport –albumin –transferin –ceruloplasmin –haptoglobin oncotic...
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Biological functions
• transport– albumin– transferin– ceruloplasmin– haptoglobin
• oncotic pressure regulation• coagulation• immunity
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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
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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
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Methods of separation
• SPE - serum protein electrophoresis
• IEP – immunoelectrophoresis• IFE – immunofixation
electophoresis
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Immunoelecctrophoresis (IEP)
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Immunofixation (IFE)
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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
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Acute phase response (APR)
• positive APR• negative APR
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beta - gamma (IgA) junction
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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
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Heavy chain disease
• lymphocytic cell proliferation• only heavy chain production
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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
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Benign monoclonal gammopathyBenign monoclonal gammopathy
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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
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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)
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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.
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• 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
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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
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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.
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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.
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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.
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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.