1. Biological functions transport –albumin –transferin –ceruloplasmin –haptoglobin oncotic pressure regulation coagulation immunity

2. Hypoproteinemia with hypoalbuminemiawith hypoalbuminemia –impairment of liver function –protein loss –changes in ECF without hypoalbuminemiawithout hypoalbuminemia –severe immunoglobulin deficiency

3. Hyperproteinemia hypergammaglobulinemiahypergammaglobulinemia –polyclonal  chronic inflammation  chronic liver disease  autoimmune diseases –monoclonal multiple myelomamultiple myeloma Waldenstrom`s macroglobulinemiaWaldenstrom`s macroglobulinemia heavy-chains diseaseheavy-chains disease dehydrationdehydration

4. Methods of separation SPE - serum protein electrophoresis IEP – immunoelectrophoresis IFE – immunofixation electophoresis

8. Immunoelecctrophoresis (IEP)

9. Immunofixation (IFE)

15. ESR Erythrocyte sedimentation rateErythrocyte sedimentation rate

16. Albumin (migrates to the anode)  -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 macroglobulin  -2 macroglobulin antithrombin IIIantithrombin III ceruloplasminceruloplasmin haptoglobin (this is usually the predominant component)haptoglobin (this is usually the predominant component) Beta globulins beta and pre-beta lipoproteins (LDL and VLDL)beta and pre-beta lipoproteins (LDL and VLDL) C3C3 C-reactive proteinC-reactive protein hemoglobin (free)hemoglobin (free) plasminogenplasminogen transferrin (*"principal component of the beta1 subdivision")transferrin (*"principal component of the beta1 subdivision") Gamma globulins ImmunoglobulinsImmunoglobulins

17. Acute phase response (APR) positive APR negative APR

21. beta - gamma (IgA) junction

23. 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

25. Heavy chain disease lymphocytic cell proliferation only heavy chain production

26. Benign monoclonal gammopathy "monoclonal gammapathy of uncertain significance""monoclonal gammapathy of uncertain significance" "MGUS”"MGUS” paraprotein < 2.0 gm/dL, Bence-Jones protein (rarely present) < 60 mg/Lparaprotein < 2.0 gm/dL, Bence-Jones protein (rarely present) < 60 mg/L

27. Benign monoclonal gammopathy

32. Acute leukemia A 7-year-old boy presented with malaise and lethargy of 6 months' duration. He had become anorexic and had lost 3kg in weight. On examination he was thin, anxious and clinically anaemic. There was mild, bilateral, cervical lymphadenopathy and moderate splenomegaly. On investigation, his haemoglobin (80g/l) and platelet count (66 x 109/l) were low, but the white-cell count was high (25 x 109/l). The blood film showed that most leucocytes were blasts; the red cells were normochromic and normocytic. Bone marrow examination showed an overgrowth of primitive white cells with diminished numbers of normal erythroid and myeloid precursors. Acute leukaemia was diagnosed. The circulating blast cells were typed by immunological methods: they did not react with monoclonal antibodies to human T-cell precursor antigens (CD2, CD7) but they were positive for major histocompatibility complex class II (DR), common acute lymphoblastic leukaemia (CD10) and B-cell precursor (CD19) antigens, and contained the enzyme terminal deoxynucleotidyl transferase (Tdt). The phenotype of the blasts was that of acute leukaemia of early precursor B cells, and the prognosis in this child is relatively good.

33. Acute leukemia On investigation, his haemoglobin (80g/l) and platelet count (66 x 109/l) were low, but the white-cell count was high (25 x 109/l). The blood film showed that most leucocytes were blasts; the red cells were normochromic and normocytic. Bone marrow examination showed an overgrowth of primitive white cells with diminished numbers of normal erythroid and myeloid precursors. Acute leukaemia was diagnosed.

35. ALL The circulating blast cells were typed by immunological methods: they did not react with monoclonal antibodies to human T-cell precursor antigens (CD2, CD7) but they were positive for major histocompatibility complex class II (DR), common acute lymphoblastic leukaemia (CD10) and B-cell precursor (CD19) antigens, and contained the enzyme terminal deoxynucleotidyl transferase (Tdt) (Table C6.1; see Fig. 6.4). The phenotype of the blasts was that of acute leukaemia of early precursor B cells (see Fig. 6.3), and the prognosis in this child is relatively good.

37. 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

38. 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)

39. 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.

40. 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

41. 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

42. 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.

43. Case 2 Her haemoglobin was 136g/l with a white-cell count of 6.7 x 10 9 /l and a normal differential. Her ESR was 34mm/h. Tests of thyroid function were normal.

44. 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.

45. 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.