SERUM PROTEIN ELECTROPHORESIS

Transcription

1 SERUM PROTEIN ELECTROPHORESIS ABD-ALLA BSC - OMDURMAN AHLIA HIGH DOPLOMA DGREE - ELZAEM EL-AZHARY FORMER HEAD OF HEMATOLOGY & BLOOD BANK MINISTRY OF HEALTH LABORATORY ADMINISTRATION KHARTOUM STATE MARKETING MANAGER-LAB EQP DIVISION ALGAM COMPANY FOR DRUGS & CHEMICAL LTD 1

2 Learning Objective *1- To see the electrophoresis development. *2-To know the fraction of protein component. *3-To know the function of different protein fraction. *4- To know the purpose of serum protein electrophoresis. *5- Understanding the questions can be answered with a serum protein electrophoresis. 2

3 Learning Objective *6- Know the pathological conditions on serum protein electrophoresis. *7- Know the monoclonal Gammopathies on serum protein electrophoresis. *8- To know position of a monoclonal immunoglobuline in serum protein electrophoresis. *9- To know the Oligoclonal pattern. 3

4 Zone Electrophoresis *The technique of zone electrophoresis has been known since 1930 by Tiselius. Initially base on the use of liquid medium, then it mature into application on solid media (zone electrophoresis) :filter paper and then cellulose acetate membrane were use to stabilize the buffer. *The electrical current flow cause the various protein particles to migrate from their point of application, into zones varying with the proteins mobility and directly related to its electrical charge. 4

5 Zone Electrophoresis *In the middle of 80s.zone electrophoresis was considerably improved by the successive introduction of agar and agarose gel. *The interest Of agarose lies above all in the initial transiency of the gel which enables to detect very faint band (e.g. early monoclonal bands)and is essential for an efficient quantitative estimate by densitometry. 5

6 Zone Electrophoresis *Most technique available in the market employ 0.5 or 1% agarose gel, that is very close to ideal liquid-medium electrophoresis system. *Low agarose concentration leads to a large pore gel which enable free migration with minimum distortion especially for high molecular weight protein and lipid molecules. 6

7 Zone Electrophoresis *There are other methods which use gels with a high resolution like polyacrylamide gels which also separate by molecular filtration according to electrical charge. *Serum protein electrophoresis remain very commonly used analytical method in the field of clinical chemistry its performed on: 7

8 Zone Electrophoresis *1- cellulose acetate medium and followed by a staining procedure in ponceau red solution. *2- increasingly on standard agarose medium or some time in high resolution agarose gel followed by staining procedure in amidoblack solution which is more sensitive than ponceau red stain and is ideal for the detection of low concentration Gammopathies. 8

9 PROTEIN ELECTROPHORESIS INTERPRETATION *The electrophoretic separation of human serum,routinely perform in alkaline solution, result in 5 to 6 clearly defined fraction, depending on the medium used: *The albumin fraction showing biochemical homogeneity is the most important among the serum proteins. *Four group of migrating globulins,(α1,α2,β and γ globulins)which group together several protein having very different function and whose quantitative variation provide invaluable information for investigation for various organ specific diseases. 9

10 PROTEIN ELECTROPHORESIS INTERPRETATION * Liver synthesizing :the protein migrating in α1,α2 and β zone, * Lymphoid tissue: synthesizing immunity protein which essentially migrate in the γ globulins zone. *The interpretation of any protein electrophoresis presuppose the knowledge of the physiopathological variation in serum specific protein and shall be necessarily complemented by quantification of serum total protein. 10

11 THE FRACTION OF PROTEIN COMPONANT *1-The albumin *2-α1 globulins: orosomucoid, α1 antitrypsin, α1 antichymotrypsin. *3- α2 globulins: haptoglobin, α2 macroglobulin, ceruleoplasmin,cg globulin, α lipoprotein. *4-β1 β2 globulins: transferrin,hemopexin,c3 complement, β lipoprotein. *5- γ globulins :IgG,IgA,IgM,(IgD, IgE) 11

12 FUNCTION OF ALBUMIN *1- Maintain the oncotic pressure. *2- transports thyroid hormones. *3- transport other hormones,in particulate ones that are fat-soluble. *4-transport fatty acids. *5- transport unconjugated bilirubin. *6- transport many drugs. *7- competitively bind calcium ions. *8- serum albumin as a negative a cute-phase protein, is down regulated in inflammatory state. *9- prevent photo degradation of folic acid. 12

13 Orosomucoid (α1type ) *OROSOMUCOID (ORM) or alpha-1- acid glycoprotein : *acute phase protein. *has normal plasma concentration between mg/ml. *plasma level are effected by pregnancy,burns, certain drugs and certain disease particularly HIV. *IT IS function is to act as a carrier of basic and neutrally charge lipophilic compound. *In medicine it is known as the primary carried of basic (positively charged). 13

14 *ALPHA 1 ANTITRIPSIN (A1AT) *ALPHA -1- ANTICHYMOTRYPSIN * ALPHA 1 ANTITRIPSIN (A1AT): *IT IS inhibit wide variety of proteases. * protect tissues from enzymes of inflammatory cell especially neutrophil elastase. *It is from g/l. *alpha -1- ANTICHYMOTRYPSIN: *act as acute phase protein that induced during inflammation. inhibit the activity of certain enzyme called protease such as : A)cathepsin G that found in neutrophil. B)chymases found in mast cell 14

15 *ALPHA-2-HAPTOGLOBIN *ALPHA-2-MACROGLOULIN *Haptoglobin function is to : *bind free plasma hemoglobin,which allow degradative enzyme to gain access to the hemoglobin. *preventing loss of iron through the kidneys * protecting the kidney from damage by hemoglobin. *Alpha 2 macroglobulin : *act as an antiprotease and is able to inactivate an enormous variety of proteinasea. *It inhibitor of fibrinolysis by inhibiting plasmin and kallikrein, it is function as an inhibitor of coagulation by inhibiting thrombin. *Act as carrier protein it can bind to numerous growth factor and cytokines. 15

16 *CERULEOPLASMIN *GC GLOBULIN *LIPOPROTEIN(α2Type ) *ceruleoplasmin : *enzyme carries more than 95% of total copper in healthy human plasma the rest is accounted for macroglobulin. *It is inhibits copper-dependant oxidase activity, which associated with possible oxidation of Fe2+,which assisting in it is transport in the plasma in association with transferrin. *GC-globulin(Vitamin D binding protein) *It is a multifunctional protein found on the surface of many cell type. * bind to vitamin D and it is plasma metabolites and transports them to the target tissue *LIPOPROTEIN: is a biochemical assembly that contains both proteins and lipids bound to protein,which allow fats to move through the water inside and outside of the cell. *the proteins serve to emulsify, transports, structural protein,antigens, adhesions and toxins are lipoproteins 16

17 TRANSFERRIN, HEMOPEXIN, C3 COMPLEMENT(β1 β2 globulins) *Transferrin: an iron-binding blood plasma glycoprotein that control the level of free iron in the biological fluids. *Hemopexin: it bind the heme with the highest affinity of any known proteins its function is scavenging the heme release or lost by the turnover of heme proteins such as hemoglobin and protects the body from the oxidative damage that free heme can cause. *C3 Complement: plays a central role in the activation of complement system. its activation is required for both classical and alternative complement activation pathway.people with C3 deficiency are susceptible to bacterial infection. 17

18 THE PATHOLOGICAL VARIATION IN SERUM TOTAL PROTEIN *The reference range for total protein is 6.5 to 8.0 g/dl in healthy adult,this value is increased by around 0.3 g/dl in plasma as it contain fibrinogen and the coagulation proteins. The total protein at birth does not exceed 4.0 to 6.0 g/dl but albumin to globulin ratio (usually between 1.2 and 1.8) is equal in children and adult. *Variation in proteinemia will result from: *1-Fluctuations in the blood volume. *2- Protein synthesis abnormality. 18

19 HYPERPROTEINEMIA *HYPERPROTEINEMIA : characterize by, The increase of the total circulating protein volume: *polyclonal or monoclonal hyper γ globulinemia. The decrease in vascular water: hemoconcentration, *Nutritional supply deficiency *Liquid loss(heat stroke,diarrhea,vomiting) 19

20 HYPOPROTEINEMIA Characterized by: * The decrease in total circulating protein volume. -Nutritional supply deficiency(malnutrition) -Absorption defect. -Protein deficiency (coetaneous,renal,intestinal). -Lack of protein synthesis in liver. *An increase in vascular water hemodilution -Water over loading. *As a general rule, any serum total protein of less than 6.0 g/dl or greater than 8.0 g/dl should be complemented by a serum electrophoresis 20

21 What s the purpose of serum protein electrophoresis? *To detect abnormalities in serum proteins: *Quantitative: increased or decreased of some fractions *Qualitative: presence of abnormal fraction(s) 21

22 Several questions can be answered with a serum protein electrophoresis confirm a pathological diagnosis in association with other parameters: inflammation, hepatitis, cirrhotic or nephrotic profile Identify the presence of a monoclonal immunoglobulin when a myeloma is suspected with clinical signs Allow an early detection of asymptomatic myeloma To monitor the evolution of malignant disease or follow the efficiency of immunosuppressive treatment 22

23 Normal serum Gaussian aspect in gamma & No increase or additional deformation/peak in gamma, beta 1, beta 2 and alpha 2 Alb α1 α2 β1 β2 γ 23

24 Quantitative changes in serum protein electrophoresis Flags allow to easily detect quantitative abnormalities 24

25 Pathological conditions on serum protein electrophoresis 25

26 Multiple Pathologies screening TP, g/dl Alb α-1 α-2 β Split β β-γ bridge γ Acute inflammatory pattern and Hyper-estrogenism pattern Chronic inflammatory disorders Hypergammaglobulinemia + Liver disease/cirrhosis Nephrotic syndrome Protein-losing pattern/malnutrition Autoimmune reactions Alpha-1-antitrypsin deficiency Hypogammaglobulinemia Hemolytic anemias/congenital hemoglobin defects Total protein, Albumin, alpha 1 & 2 zones, beta zone, gamma zone (gammaglobulins ) 26

27 Inflammation Acute inflammation associated with : - increase of α1 and α2 globulins due to an increase of: orosomucoid, alpha-1 antitrypsin and haptoglobin - decrease of albumin Chronic inflammation associated with : - increase of alpha-1, alpha-2 globulins - polyclonal increase of gamma globulins - decrease of albumin 27

28 Acute Inflammation HPT A1AT ORO Alb α1 α2 β1 β2 γ Complementary immunofixation/immunotyping not AHMED MOHAMED required. Recheck thenazar electrophoresis in 3 months 28

29 Chronic Inflammation Increase of polyclonal Ig A in beta 2 and G in gamma Alb α1 α2 β1 β2 γ Complementary immunofixation/immunotyping not AHMED MOHAMED required. Recheck thenazar electrophoresis in 3 months 29

30 Nephrotic syndrome This disease is associated with : A decrease of albumin, alpha-1 globulins An increase of alpha-2 globulins (due to an increase of alpha-2 macroglobulin) On capillary systems: lipoproteins migrate inside albumin fraction no increase of beta globulins, but deformation of albumin fraction may occur Note: On gel: increase of alpha 2 and beta globulins (due to an increase of alpha-2 macroglobulin and alpha and beta lipoproteins in lipoid nephrosis) 30

31 Nephrotic syndrome Total protein concentration is decreased (under 60g/l or 6g/dl) Alpha 2 macroglobuline Alb α1 α2 β1 β2 γ Complementary immunofixation/ immunotyping not required ifnazar nephrotic syndrome is corroborated AHMED MOHAMED 31 by serum lipid results

32 Cirrhotic profile This disease is associated with : A polyclonal increase of beta2-gamma globulins (beta2-gamma bridge due to polyclonal increase of Ig A in beta) Hepatocellular insufficiency can also lead a decrease of albumin, alpha 1 and alpha 2 to 32

33 Beta 2 gamma bridge (Polyclonal increase of Ig A in beta 2 and Ig G in gamma) Immunotyping/Immunofixation is not required in case of known liver disease or positive liver function tests 33

34 Hypogammaglobulinemia Decrease of polyclonal immunoglobulins in gamma zone It is associated with : -Partial or total immunodeficiency - Immunosuppressive treatment - Free light chains disease or non secreting myeloma 34

35 Hypogammaglobulinemia If the clinical causes of This Hypogammaglobulinemia are unknown, it is NAZAR AHMED MOHAMED advisable to check 24h urine for Bence Jones protein. 35

36 Hypergammaglobulinemia Increase of polyclonal immunoglobulins in gamma zone It is associated with : - Inflammation - Cirrhosis - Sub acute and chronic infections 36

37 Congenital deficiency of A1AT in alpha 1 To follow this isoled alpha 1 decrease, a complementary A1AT quantification was performed. A1AT = 0.17g/L (normal ranges: g/l). Alb NAZAR α1ahmedα2 β1 β2 MOHAMED γ 37

38 Chronic inflammatory profile with underlying distortion in gamma Immunotyping/Immnofixation is required. NAZARwithin AHMED MOHAMED For repeat testing the next 3 to 6 months 38

39 Double albumin: a bisalbuminemia or something else? Possible causes : Congenital bisalbuminemia (genetic mutation) Bisalbuminemia due to acute pancreatitis: the release of pancreatic enzymes can lead to albumin splitting or Lipoproteins (check milky serum aspect) Biliary pigments (check icteric serum aspect) Due to a recent injection of X-ray contraste products in blood circulation. Ask a new sample within 4 days Some antibiotics: transitory bisalbuminemia due to drug interaction with albumin Complementary immunofixation/ immunotyping not required NAZAR AHMED MOHAMED 39

40 A Small additional fraction in albumine? Possible causes : Lipoproteins (check milky serum aspect) Biliary pigments (check icteric serum aspect) Due to a recent injection of X-ray contrast products in blood circulation. Ask a new sample within 4 days Some antibiotics: transitory bisalbuminemia due to drug interaction with albumin Capillary aging If the same phenomena is found on all analyses on the same capillary Complementary immunofixation/ NAZAR AHMED MOHAMED immunotyping not required 40

41 An additional fraction in albumin? Possible causes : Lipoproteins (check milky serum aspect) Biliary pigments (check icteric serum aspect) Due to a recent injection of X-ray contrast products in blood circulation. Ask a new sample within 4 days Some antibiotics: transitory bisalbuminemia due to drug interaction with albumin Complementary immunofixation/ NAZAR AHMED MOHAMED immunotyping not required 41

42 Lipoprotéines, biliary pigments 42

43 A Small additional fraction in alpha 1? Heterozygote phenotype of A1AT Alb α1 α2 β1 β2 γ Complementary immunofixation/ immunotyping not required 43

44 Hétérozygote phénotype of A1AT A1AT α1mohamedα2 Alb NAZAR AHMED β1 β2 γ 44

45 An additional fraction in alpha 2? Double peaks in alpha 2 in case of: - Hemolysed sample (haptoglobin-hemoglobin complex). Check the serum aspect and ask a new sample in case of hemolyzed sample - Specific phenotypes of Haptoglobin (genetic mutation) - Presence of a monoclonal immunoglobulin with anodic mobility 45

46 Hemolyzed sample Complex Hpt-Hb Alb α1 α2 β1 β2 Free Hb γ Sample not recommended by Sebia, ask a new sample 46

47 Haptoglobin phenotypes in alpha 2 zone Phenotype I - I Phenotype I - II Phenotype II - II 47

48 An additional fraction in alpha 2? If the patient is known for a gammopathy or indicates clinical signs for a gammopathy, perform an immunotyping If there is no information available for the patient, consider the alpha 2 value (in g/l or g/dl) and the context present on the electrophoretic profile If Patient alpha 2 value > Phoresis reference alpha 2 value without a context of inflammatory response, perform a immunotyping for a potential monoclonal immunoglobulin Patient alpha 2 value < Phoresis reference alpha 2 value without a context of inflammatory response, recheck the serum protein electrophoresis in 3 months If Patient alpha 2 value > Phoresis reference alpha 2 value with a context of inflammatory response, recheck the serum protein electrophoresis in 3 months 48

49 An additional fraction in alpha 2: monoclonal Ig? Patient alpha 2 value > Phoresis reference alpha 2 value (in g/l or g/dl) without a context of inflammatory response => Perform a immunotyping for a potential monoclonal immunoglobulin 49

50 An additional fraction in beta 2? Double peaks in beta 2 in case of: - Presence of fibrinogen (plasma/ serum with anti-clotting treatment). Plasma sample is not recommended, request a new sample. - Presence of a monoclonal immunoglobulin - Presence of C4 complement in case of inflammatory response - Presence of X-ray contrast products. Ask a new sample within 4 days 50

51 Fibrinogen in beta 2 (plasma or serum with anti-clotting treatment) Fibrinogen On gel electrophoresis: fibrinogen gives an extra band in the gamma fraction instead of beta 2 Alb α1 α2 β1 β2 γ IF/IT required: In both immunofixation or immunotyping, AHMED MOHAMED the antisera will not reactnazar with Fibrinogen 51

52 C4 complement in beta 2 on an acute inflammatory profile C4 Alb α1 α2 β1 β2 γ IF/IT required: In both immunofixation or immunotyping, the antisera will not react with C4 complement 52

53 C-Reactive Protein (CRP) in gamma on an acute inflammatory profile - Protidemia= 59 g/l CRP = 200mg/L IF/IT required: In both immunofixation or immunotyping, the antisera will not react with CRP 53

54 Monoclonal Gammopathies on serum protein electrophoresis 54

55 Immunoglobulin molecule Light chain (κ or λ) ~ 25 kda determine Ig type Heavy chain (γ, α, µ, δ or ε) ~ 55 kda determine Ig class (G, A, M, D or E) Disulfure bridge Each B lymphocyte, differentiated in a plasmocyte, produces an immunoglobulin (Ig) ~ 160 kda with 2 identical heavy chain and 2 identical light chain Igs are involved in the immune response against infections 55

56 Gammopathy and monoclonal immunoglobulin P1 P2 P3 P4 P5 Normal plasmocyte Secretion of a single immunoglobulin by plasmocyte at a similar rate Serum Polyclonal immunoglobulins Malignant transformation of a plasmocyte P1 P2 P3 P4 The proliferation of this malignant plasmocyte leads to an excess of his secreted immunoglobulin in the serum Serum Polyclonal immunoglobulins Monoclonal immunoglobulin 56

57 Serum protein electrophoresis and detection of monoclonal immunoglobulin Normal plasmocytes P1 P2 P3 P4 P5 Polyclonal immunoglobulins Malignant transformation of a plasmocyte Polyclonal Immunoglobulins Monoclonal immunoglobulin Qualitative and/or quantitative modifications of serum protein electrophoresis 57

58 Gammopathies characterized by the presence of a serum monoclonal immunoglobulin Symptomatic gammopathies: Multiple Myeloma (MM) Waldenström disease Non Hodgkins Lymphoma Chronic Lymphoïd Leukemia Heavy chain disease Amyloidosis Asymptomatic gammopathies: Smoldering myeloma (SM) Monoclonal Gammopathies of Undetermined Significance (MGUS) 58

59 Classification of monoclonal gammopathies MGUS Smoldering myeloma Multiple myeloma < 30 g/l > 30 g/l* No threshold Clonal bone marrow plasma cells < 10% > 10 %* > 10% End -organ damage** M-protein concentration At least one of these 2 criteria must be present ** End-organ damage: C Hyper Calcemia (Ca > 10,5mg/dL) R Renal insufficiency (Creatinine>2mg/dL) A Anemia (Hb <10g/dL) B Lytic Bone lesions Kyle & Rajkumar, 2009: Leukemia,23(1):3-9 59

60 Distribution of gammopathies for newly discovered monoclonal immunoglobulins Study Patients MGUS Multiple Myeloma Other LPS WM AL Malmö ( ) % 19% 6% 2% 1% Mayo clinic (2005) % 24% 4% 3% 11% Others 6% MGUS: Monoclonal gammopathies of undetermined significance WM: Waldenström macroglobulinemia Other LPS: Smoldering myeloma, Plasmocytoma Others: Chronic lymphoïd leucemia, non hodgkinien lymphoma.. Kyle & Rajkumar, 2006: Br J Haematol,134(6):

61 Position of a monoclonal immunoglobulin in serum protein electrophoresis Presence of a peak or distorsion in gamma Presence of an additional peak or an additional distorsion in beta 1 or beta 2 Beta 2 beta 1 without an inflammatory context or hepatic disease (increased alpha 1 and alpha 2 fractions, decreased albumin) Isolated increase or not of beta 1 (without a hemolyzed serum or an iron deficiency anemia) Patient alpha 2 value > reference alpha 2 value without an inflammatory context 61

62 Strong monoclonal immunoglobulin in the gamma zone Alb α1 α2 β1 β2 Complementary immunofixation/ Immunotyping required γ 62

63 Monoclonal immunoglobulin peak in gamma Complementary immunofixation/ Immunotyping required 63

64 Weak monoclonal immunoglobulin in the gamma zone Alb α1 α2 β1 β2 γ Complementary immunofixation/ Immunotyping required 64

65 Weak distortion in gamma (monoclonal immunoglobulin) Alb α1 α2 β1 β2 Complementary immunofixation/ Immunotyping required γ 65

66 Weak distortion in gamma (monoclonal immunoglobulin) Alb α1 α2 β1 β2 γ Complementary immunofixation/ Immunotyping required 66

67 Weak monoclonal immunoglobulin peak on hypogammaglobulinemia Alb α1 α2 β1 β2 γ Complementary immunofixation/ Immunotyping required 67

68 68

69 Monoclonal immunoglobulin distorsion in beta 1 Additional peak or isolated increase of Beta 1 without iron anemia Alb α1 α2 β1 β2 γ Complementary immunofixaton/ Immunotyping required 69

70 An additional fraction in alpha 2: monoclonal Ig? Patient alpha 2 value > Phoresis reference alpha 2 value (in g/l or g/dl) without a context of inflammatory response => Perform a immunotyping for a potential monoclonal immunoglobulin 70

71 Highly polymerized monoclonal immunoglobulin or something else? Warning: Migration is out of range indicates a delay of albumin migration. If the problem only appears on a sample out of the serie, the sample must be treated by BME/fluidil for a suspicion of highly polymerized monoclonal immunoglobulin 71

72 Treatment with Beta Mercaptoethanol (BME) to depolymerize a monoclonal Ig * Prepare a 1% BME reducing solution : 1) 90µL H2O + 10µL BME 2) 10µL 1/10 diluted BME + 90µL Fluidil (ref 4587) * 100µL of 1% BME reducing solution + 300µL serum * Incubate 10 mn at room temperature Analyze immediately the treated sample in Capillarys or Minicap without any delay To depolymerize Ig M, Ig A and free light chains 72

73 NAZAR centering AHMED MOHAMED «Migration out of range» 73

74 Before BME After BME After BME/Fluidil treatment for the same sample 74

75 Limit of sensitivity for monoclonal band detection Between g/l according to the mobility of the Mc and the polyclonal background Das Bildelement mit der Beziehungs-ID rid3 wurde in der Datei nicht gefunden g/l 75

76 Limit of sensitivity for monoclonal band detection Between g/l according to the mobility of the Mc and the polyclonal background 0.4 g/l 76

77 High resolution of Capillarys/Minicap to detect a weak monoclonal Ig Zoom + smoothing 0 77

78 High resolution of Capillarys/Minicap to detect a weak monoclonal Ig Zoom +smoothing 0 78

79 Quantification of a monoclonal immunoglobulin on serum protein electrophoresis The quantification is required for: Myeloma classification (MGUS, SM or symptomatic myeloma) Staging of symptomatic myeloma (stage I, II and III) To monitor an increase of malignant disease or the evolution from a non malignant state to a malignant state 79

80 Quantification of a monoclonal immunoglobulin on serum protein electrophoresis Peak quantitation on protein electrophoretic curve It is the most accurate quantitation: Requires: * accurate total protein measurement * accurate determination of the peak Nephelometric or turbidimetric measurement This measurement includes the concentration of the entire Ig class (monoclonal and polyclonal). This measurement may lead to significant discrepancies 80

81 Oligoclonal pattern *Oligoclonal: Refers to the presence of multiple, faint, narrow, and homogenous bands. *Hypergammaglobulinemia is due to an increase of several subclasses of immunoglobulins, that gives a picture of multiple "monoclonal" bands called "oligoclonal profile" or oligoclonal bands. 81

82 Oligoclonal pattern is observed in: autoimmune reactions associated with transplants In patients under immuno-suppressive treatment in case of autoimmune diseases (rheumatoid arthritis, Gougerot-Sjögren syndrome, lupus erythematosus) infectious (viral, bacterial and parasitic) diseases (H.I.V., viral hepatitis, cytomegalovirus infection.) 82

83 Potential oligoclonal profile in gamma Complementary immunofixation/immunotyping required to distinguish an oligoclonal profile from a risk of polymerized monoclonal immunoglobulin 83

84 Do not report an oligoclonal profile in gamma, just because multiple distorsions are visible in gamma with an inflammatory profile! +BME No oligoclonal profile here but a polymerized Ig M 84

85 Potential oligoclonal profile with hypergamma Alb α1 α2 β1 β2 γ Prefer complementary Immunotyping to distinguish oligoclonal profile from high polyclonal background. In immunofixation oligoclonal profile may be hidden bynazar thisahmed highmohamed polyclonal background 85

86 Serum Electrophoresis interpretation 86

87 Faint distortion in gamma Complementary Immunotyping / Immunofixation is required NAZAR AHMED MOHAMED 87

88 Strong monoclonal peak in gamma Complementary Immunotyping / Immunofixation is required NAZAR AHMED MOHAMED 88

89 Chronic inflammatory profile Complementary Immunotyping / Immunofixation is not NAZAR AHMED required. Recheck the electrophoresis in 3MOHAMED months 89

90 Hypogammaglobulinemia If the clinical causes of this hypogammaglobulinemia are unknown, it is NAZAR AHMED MOHAMED advisable to check 24h urine for Bence Jones protein. 90

91 Acute Inflammatory Profile (Beta 2 = Beta 1 due to polyclonal increase of Ig A) Complementary Immunotyping / Immunofixation is NAZAR AHMED MOHAMED not required. Recheck the electrophoresis in 3 months 91

92 Beta 2 gamma bridge (Polyclonal increase of Ig A in beta 2 and Ig G in gamma) Immunotyping/Immunofixation is not required in case of known liver disease or positive liver function tests 92

93 Monoclonal peak in gamma Complementary Immunotyping / Immunofixation is required NAZAR AHMED MOHAMED 93

94 1. Acute inflammatory profile 2. Monoclonal peak in gamma and hypogammaglobulimemia Complementary Immunotyping / Immunofixation is required 94

95 Isolated increase of alpha 2 fraction Complementary Immunotyping / Immunofixation is required NAZAR AHMED MOHAMED 95

96 Monoclonal Peak in gamma Complementary Immunotyping / Immunofixation is required NAZAR AHMED MOHAMED 96

97 Beta 2-gamma bridge (Cirrhotic profile) Immunotyping is not required in case of known liver disease or positive liver function tests 97

98 Chronic inflammatory profile with underlying distortion in gamma Immunotyping/Immnofixation is required. NAZARwithin AHMED MOHAMED For repeat testing the next 3 to 6 months 98

99 Chronic inflammatory profile with a weak monoclonal peak Double aspect in alpha 2 could be due a HPT mutation Complementary Immunotyping / Immunofixation is NAZAR AHMED MOHAMED required. For repeat testing within the next 3 to 6 months 99

100 Potential oligoclonal profile in gamma Complementary Immunotyping / Immunofixation is required. For repeat testing within the next 3 to 6 months 100

101 Monoclonal Peak in gamma NAZAR AHMED MOHAMED Complementary Immunotyping / Immunofixation is required 101

102 Nephrotic profile Complementary Immunotyping / Immunofixation is not required if nephrotic syndrome is corroborated by serum lipid results 102

103 Inflammatory profile with potential oligoclonal profile in gamma Complementary immunotyping/immunofixation is required. For repeat testing within the next 3 to 6 months NAZAR AHMED MOHAMED 103

104 Monoclonal peak in beta 2 and hypogamma Complementary Immunotyping / Immunofixation is required 104

105 ANY QUESTION? 105

106 Learning Outcome *1- See the electrophoresis development. *2- Knowing the fraction of protein component. *3-See the function of different protein fraction. *4- Knowing the purpose of serum protein electrophoresis. *5- Knowing the questions can be answered with a serum protein electrophoresis. 106

107 Learning Outcome *6- Knowing the pathological conditions on serum protein electrophoresis. *7-Understanding Monoclonal Gammopathies on serum protein electrophoresis. *8- See the Position of a monoclonal immunoglobuline in serum protein electrophoresis. *9- Understanding the Oligoclonal pattern. 107

108 Summary *Serum protein electrophoresis is used to identify patients with multiple myeloma and other serum protein disorders. *Electrophoresis separates proteins based on their physical properties, and the subsets of these proteins are used in interpreting the results. *Plasma protein levels display reasonably predictable changes in response to acute inflammation, malignancy, trauma, necrosis, infarction, burns, and chemical injury. 108

109 THANK YOU FOR GOOD ATTENTION 109