Incidence and Management of Therapeutic Monoclonal Antibody Interference in Monoclonal Gammopathy Monitoring.

BACKGROUND: The treatment of multiple myeloma (MM) has been revolutionized by the introduction of therapeutic monoclonal antibodies (tmAbs). Daratumumab, a human IgG1/κ tmAb against CD38 on plasma cells, has improved overall survival in refractory MM and was recently approved as a frontline therapy for MM. Work on tmAb interference with serum protein electrophoresis (SPE) during MM monitoring has failed to provide information for laboratories on incidence of interference and effective methods of managing the interference at a practicable level. We aimed to evaluate daratumumab and elotuzumab interference in a large academic hospital setting and implement immediate solutions. METHODS: We identified and chart reviewed all cases of possible daratumumab interference by electrophoretic pattern (120 of 1317 total cases over 3 months). We retrospectively reviewed SPE cases in our laboratory to assess clinical implications of tmAb interference before the laboratory was aware of tmAb treatment. We supplemented samples with daratumumab and elotuzumab to determine the limits of detection and run free light chain analysis. RESULTS: Approximately 9% (120 of 1317) of tested cases have an SPE and/or immunofixation electrophoresis (IFE) pattern consistent with daratumumab, but only approximately 47% (56) of these cases were associated with daratumumab therapy. Presence of daratumumab led to physician misinterpretation of SPE/IFE results. Limits of daratumumab detection varied with total serum gammaglobulin concentrations, but serum free light chain analysis was unaffected. CONCLUSIONS: Clinical laboratories currently rely on interference identification by electrophoretic pattern, which may be insufficient and is inefficient. Critical tools in preventing misinterpretation efficiently include physician education, pharmacy notifications, separate order codes, and interpretive comments.

[Electrophoretic Analysis of Serum Lipoproteins: Its Usefulness and Problems].

Analysis of serum lipoprotein fractions by electrophoresis (lipoprotein electrophoresis) reveals lipid metabolism disorders, and provides various types of bio-information which lead to an accurate diagnosis and effective treatment for dyslipidemia and related diseases (e.g., coronary artery disease or chronic kidney disease). In particular, lipoprotein electrophoresis enables us to define the phenotypes of dyslipidemia, and to detect abnormal lipoproteins, which are potent biomarkers of atherosclerotic disease. In addition, lipoprotein electrophoresis is an indispensable complement to other assay methods for serum lipid component measurement that have some limitations, such as a homogeneous assay for LDL-C. However, it appears to be underestimated regarding its clinical usefulness. Indeed, the fee for lipoprotein electrophoresis tests is too low. This review specifically discusses the clinical usefulness and problems of lipoprotein electrophoresis, with a special emphasis on cost.

Optimization of utilization of serum protein analysis: role of the electronic medical record in promoting consultation by pathology.

Screening for monoclonal gammopathies is usually done by serum protein electrophoresis (SPEP) and serum free light chain tests. SPEP may be followed by immunofixation electrophoresis (IFE). IFE may be ordered by the treating physician or be at the discretion of the pathologist. We examined the appropriateness of IFE ordering by treating physicians and report on our findings, follow-up changes to the ordering process, and results of the change. We retrospectively analyzed the data from our laboratory from April 2009 through July 2012. In April 2009, 3 options for test ordering were available for the clinicians: SPEP with reflex IFE, SPEP only, and SPEP with IFE. This test ordering option was limited to SPEP with reflex IFE only in April 2010. We compared the rates of SPEP and IFE performed in the 2 periods (ie, April 2009 through April 2010 and May 2010 through July 2012). There was a substantial drop in the IFE/SPEP ratio from 0.47 to 0.21. Review of electronic medical records by the consultant pathologist was instrumental in improving the utilization and enhancing the value of pathology consultation. Possible impacts on laboratory costs, revenue, and overall health care are also presented.

Comparative response assessment by serum immunoglobulin M M-protein and total serum immunoglobulin M after treatment of patients with Waldenström macroglobulinemia.

Serum immunoglobulin (Ig) M monoclonal protein determined by electrophoresis (sIgM-MP) and total serum IgM (sIgM) by nephelometry are widely used for response assessment in Waldenström macroglobulinemia (WM), although have not been compared for predicting changes in underlying disease burden. We, therefore, compared these serum markers with changes in bone marrow (BM) and extramedullary disease for 73 patients who were rituximab naive and treated with a rituximab-containing regimen. By linear regression analysis, reductions in sIgM-MP and sIgM showed moderate correlation with BM disease involvement (r = 0.4051 and r = 0.4490, respectively), and did not differ from one another as estimators of BM disease response (P = .3745). Neither sIgM-MP nor sIgM showed a strong correlation with BM disease response in patients with low (<1000 mg/dL) or high (>5000 mg/dL) IgM levels and extramedullary disease response. sIgM-MP and sIgM, therefore, are comparable response markers in WM. Development of newer, more accurate surrogate response markers are needed to better delineate treatment outcomes in patients with WM and with low or high IgM levels, and extramedullary disease.

Assessment of the diagnostic performances of IgA heavy and light chain pairs in patients with IgA monoclonal gammopathy.

OBJECTIVES: Preliminary results of the IgA Hevylite™ assay including the establishment of the 95% reference interval and assessment of the specificity and sensitivity in different populations are reported. DESIGN AND METHODS: The concentrations of IgA heavy and light chains (HLC) enabling to determine an IgAκ/IgAλ ratio were quantified in 119 apparently healthy individuals to generate 95% reference intervals. The specificity of this assay was assessed in 48 patients with an isolated polyclonal IgA increase. In a retrospective analysis of 68 patients with a monoclonal component type IgA (MC-IgA) identified by serum immunofixation (IFE), IgA HLC ratio values were compared with known results for serum protein electrophoresis (SPE) and free light chain (FLC) ratios. RESULTS: The 95% reference range obtained in 119 controls (0.91-2.04) was close to that quoted by the manufacturer (0.80-2.04). Eight of the 48 patients (16.7%) with a polyclonal IgA increase had an IgA HLC ratio above the upper limit of the 95% reference interval. The IgA HLC ratio identified 65 (95.6%) among 68 patients with MC-IgA identified on the basis of IFE. For 34 of these patients (50%), MC-IgA was not detected by SPE due to its co-migration with alpha-2 or beta-globulins. CONCLUSIONS: Compared with serum IFE, the IgA HLC ratio has a sensitivity of 95.6%. Further studies are needed to assess the specificity of the IgA HLC ratio in patients with an isolated polyclonal increase of serum IgA.

Tests and expenditures in the initial evaluation of peripheral neuropathy.

BACKGROUND: Peripheral neuropathy is a common disorder in which an extensive evaluation is often unrevealing. METHODS: We sought to define diagnostic practice patterns as an early step in identifying opportunities to improve efficiency of care. The 1996-2007 Health and Retirement Study Medicare claims-linked database was used to identify individuals with an incident diagnosis of peripheral neuropathy using International Classification of Diseases, Ninth Revision, codes and required no previous neuropathy diagnosis during the preceding 30 months. Focusing on 15 relevant tests, we examined the number and patterns of tests and specific test utilization 6 months before and after the incident neuropathy diagnosis. Medicare expenditures were assessed during the baseline, diagnostic, and follow-up periods. RESULTS: Of the 12, 673 patients, 1031 (8.1%) received a new International Classification of Diseases, Ninth Revision, diagnosis of neuropathy and met the study inclusion criteria. Of the 15 tests considered, a median of 4 (interquartile range, 2-5) tests were performed, with more than 400 patterns of testing. Magnetic resonance imaging of the brain or spine was ordered in 23.2% of patients, whereas a glucose tolerance test was rarely obtained (1.0%). Mean Medicare expenditures were significantly higher in the diagnostic period than in the baseline period ($14,362 vs $8067, P < .001). CONCLUSIONS: Patients diagnosed as having peripheral neuropathy typically undergo many tests, but testing patterns are highly variable. Almost one-quarter of patients receiving neuropathy diagnoses undergo high-cost, low-yield magnetic resonance imaging, whereas few receive low-cost, high-yield glucose tolerance tests. Expenditures increase substantially in the diagnostic period. More research is needed to define effective and efficient strategies for the diagnostic evaluation of peripheral neuropathy.

Quantitative assessment of the kinetics of growth factors release from platelet gel.

BACKGROUND: The time course of the release of growth factors from platelet (PLT) gels has not been thoroughly studied and should be elucidated for a better standardization of the clinical use of these products. STUDY DESIGN AND METHODS: Release of PLT-derived growth factor-AB (PDGF-AB), transforming growth factor-beta1 (TGF-beta1), epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), and insulin-like growth factor-1 (IGF-1) was determined 5, 60, 120, and 300 minutes after PLT gel formation. Control experiments where PLT gel was removed and, afterward, exogenous thrombin was added, were also performed. Protein profiles of the PLT concentrates and of the releasates were determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). RESULTS: Mean PDGF-AB, TGF-beta1, EGF, and VEGF concentration increased to 76, 114, 3.7, and 0.8 ng per mL, respectively, in the presence of the PLT gel, but remained at approximately 28, 30, 0.28, and 0.34 ng per mL, respectively, when the PLT gel was removed after formation. IGF-1 content remained unchanged (approx. 80 ng/mL). SDS-PAGE analysis showed that several PLT proteins disappear during PLT gel formation and that the protein patterns of the releasates were undistinguishable at the different time points. CONCLUSION: There is a gradual and fast release of PDGF-AB, TGF-beta1, EGF, and VEGF from PLT gel for at least 60 to 300 minutes after gel formation, whereas the IGF releasate concentration remains unchanged. This study may provide useful information to improve clinical applications of PLT gels and to design improved blood-derived biomaterials with controlled release of growth factors.

Assessment of serum protein electrophoresis for monitoring therapy of naturally acquired equine cyathostomin infections.

Serum protein electrophoresis (SPE) has previously been suggested as a means of assessing cyathostomin burdens in horses, although SPE used for that purpose is supported by little evidence. This clinical research report describes a study that objectively evaluated the use of SPE on a population of 38 horses following the administration of different anthelmintics. The population was subdivided into three groups, Groups F, M and P: 7.5 mg/kg bwt fenbendazole was administered to Group F on day -12; on day 0 0.4 mg/kg bwt moxidectin was administered to Group M and 19 mg/kg bwt pyrantel was administered to Group P. Faecal worm egg counts were obtained on days -14, 0 and 10. Groups M and P acted as controls for the Group F faecal egg count reduction test (FECRT) in which a high level of benzimidazole resistance was demonstrated. Group F was then used as a control group for the FECRT for both Groups P and M. A high anthelmintic efficacy of moxidectin and pyrantel was detected. SPE was performed on venous blood collected on days 0, 10, 30, 56 and 80. As the cyathostomins infecting the horses had been shown to be highly resistant to fenbendazole, Group F then served as a control group for comparison of any changes in protein fractions. Serum proteins did not vary significantly between groups on any of the sampling dates. No significant changes in serum proteins were observed in any group and no patterns were apparent on qualitative assessment of SPE profiles. SPE was therefore concluded to be an insensitive tool for the monitoring of cyathostomin treatment in horses in a clinical environment.

A rapid, economical, and reproducible method for human serum delipidation and albumin and IgG removal for proteomic analysis.

Serum is a readily available source for diagnostic assays, but the identification of disease-specific serum biomarkers has been impeded by the dominance of human serum albumin (HSA) and immunoglobulin G (IgG) in the serum proteome. Therefore, in order to observe lower-abundance serum proteins, removal or depletion of at least these two proteins is required. However, the depletion method needs to be inexpensive and reproducible. We describe such a protocol that combines delipidation by centrifugation, IgG removal with Protein G Sepharose, and HSA depletion with sodium chloride/ethanol precipitation. The protocol is streamlined to increase reproducibility and is compatible with many proteomic platforms, including two-dimensional gel electrophoresis, and high-performance liquid chromatography either offline or coupled online with a mass spectrometer. The reproducible depletion of lipids, IgG, and HSA permits a higher load of the remaining serum proteins, facilitating the identification of disease biomarkers.

Serum free light chains: an alternative to the urine Bence Jones proteins screening test for monoclonal gammopathies.

BACKGROUND: Retrospective analyses have established the role of quantitative serum free light chains (FLCs) in the diagnosis of monoclonal light chain disorders. The aims of this study were to assess (a) whether the addition of serum FLCs to serum protein electrophoresis (SPEP) identified additional patients with monoclonal gammopathies; (b) whether serum FLC measurements could replace urinalysis for Bence Jones protein (BJP); and (c) the cost/quality implications of routinely measuring serum FLCs. METHODS: Serum FLCs were added to consecutive requests for SPEP from August to November 2004 and measured by automated immunoassay. RESULTS: Seventy-one of 923 patients had abnormal serum FLC ratios. Seven patients with monoclonal gammopathies and 1 patient with malignant lymphoma (but no monoclonal band) were detected among 43 patients with negative SPEP but positive serum FLC ratios. Thirty-five patients with negative SPEP had false-positive serum FLC ratios. The false-positive rate for a ratio >1.65 was higher than previously described and associated with polyclonal increases in immunoglobulins and renal impairment. Serum FLC ratios were normal in 2 of 13 patients with low-level persistent urine BJP. However, no significant pathology would have been missed by replacing BJP with serum FLCs. Revenue and manpower savings offset 60% of the costs of serum FLCs. CONCLUSIONS: Additional diagnostic information is gained by adding serum FLCs to SPEP as first-line tests for investigating possible B-cell disorders. The quality of the diagnostic service is enhanced by more confident exclusion of light chain disorders and improved interpretive assessment of SPEP and immunofixation electrophoresis.

Assessment of serum free light chain assays for plasma cell disorder screening in a Veterans Affairs population.

This study evaluated serum kappa and lambda free light chain (FLC) concentrations in a Veterans Affairs (VA) population. We hypothesized that our older, mostly male, population should not differ in serum FLC ranges from levels previously established for younger male and female populations and that the assay would improve our screening protocol for plasma cell dyscrasias (PCD). Serum kappa and lambdaFLC were assayed in 312 consecutive serum samples collected during a 16-week period from veterans whose clinical presentation indicated a need for serum protein electrophoresis (SPEP) analysis. We reviewed our laboratory information system (LIS) files to evaluate the patients' diagnoses and treatment status in conjunction with serum FLC levels. All assays and validation studies were conducted using an immunoturbidimetric method with a Roche/Hitachi 911 modular analytical system. The intra-assay variability (CV) was <5%, based on 13 replicate assays of 4 control samples and 1 blank sample. Of the 312 patients, the SPEP results were normal in 235 and abnormal in 77. Of the 235 patients with normal SPEP results, 37 had abnormal FLC values and 20 of these were diagnosed as PCD. Of the 77 patients with abnormal SPEP results, only 9 had diagnoses unrelated to PCD. Using the FLC assay in conjunction with retrospective reviews of medical records, we obtained an 86% detection rate of PCD. This detection rate increased to 100% when both SPEP and FLC results were considered. In conclusion, this study documents an important role for serum FLC assays in diagnosing and monitoring PCD in a VA population. Our results support previously established serum FLC reference ranges that were obtained in younger, male and female populations. Using the serum FLC results in conjunction with SPEP results improves the sensitivity and specificity for managing VA patients whose clinical presentation indicates the need to evaluate PCD.

Assessment of the reliability of plasma electrophoresis in birds.

OBJECTIVE: To determine the reliability of plasma electrophoresis (EPH) in psittacine birds. ANIMALS: 93 psittacine birds. PROCEDURE: Jugular venipuncture was performed on 93 awake psittacine birds. The plasma was centrifuged, separated, aliquoted into duplicate samples, frozen, and sent to 2 commercial laboratories that routinely perform avian EPH. Samples from 51 birds were sent to laboratory A, and samples from 42 birds were sent to laboratory B. The reliability of EPH results within each laboratory was assessed, but not between laboratories. To determine the reliability (agreement between duplicate samples) of total protein, albumin, prealbumin, alpha1-, alpha2-, beta-, and gamma-globulin concentrations, the intraclass correlation coefficient (r(i)) was calculated. RESULTS: Both laboratories had excellent agreement between samples for measurement of total protein concentration and only good agreement for albumin concentration. Except for the prealbumin concentration measured at laboratory B, both laboratories had poor agreement for all other values of the EPH. CONCLUSIONS AND CLINICAL RELEVANCE: These data indicate that plasma EPH for measuring prealbumin, alpha1-, alpha2-, beta-, and gamma-globulin concentrations may not be a reliable tool for assessing avian health. Small amounts of these proteins in birds plus human variation in reading the EPH curves may lead to variable results. Avian veterinarians should cautiously interpret results from plasma EPH assays for these protein fractions.

Economical choices in setting up a diagnostic myeloma laboratory.

In setting up a diagnostic myeloma laboratory the popular, highly automated and otherwise excellent choices of equipment and laboratory practices, so exorbitantly raise costs that the sustainability, even in large government hospitals in third world countries may become difficult. Based on our experience in a regional cancer center in India, we offer here, guidelines for carrying out high resolution electrophoresis, densitometry, immunofixation and urine concentration. We show that by simply employing well established techniques and doing them properly, one can get results of excellent quality at minimum cost and minimum dependence on costly imports.

IgD-kappa myeloma: an unusual case.

A rare case of biclonal IgD-kappa and IgG-kappa myeloma is described. The patient initially presented with anemia, renal insufficiency, and proteinuria. The IgD-kappa, initially, was overlooked as a light chain; however, it decreased in serum concentration after treatment by approximately 90%, in contrast to the IgG-kappa that decreased in serum by approximately 40 % over a 9-yr period. Clinically, the patient responded well to treatment and improved greatly during this period. Practical recommendations are suggested in order to detect such cases.

The generation of narrative interpretations in laboratory medicine: a description of service-specific sign-out rounds.

The logistical details for organizing effective interpretive rounds in a laboratory medicine subspecialty must be carefully established so that expert opinions are provided in a timely fashion in a patient-specific report, rather than as a collection of fixed comments associated with a particular laboratory result generated by a computer This report describes the test batteries for interpretations, the billing for interpretations, clinical examples of interpretations, and interpretations for which billing is not typically performed in several clinical or laboratory areas in our institution. These include coagulation disorders, hemoglobin and anemia evaluations, autoimmune disorders, serum protein analysis, toxicology, molecular diagnostics, and transfusion medicine. The information in this report should provide sufficient detail to allow development of interpretive services with successful billing for the areas in laboratory medicine described.

[An assessment of the degree of chromophore photo damage to the heme and globin components in UV-irradiated molecules and electrophoretic fractions of human carboxyhemoglobin]. / Otsenka stepeni fotopovrezhdeniia khromoforov gemovogo i globinovogo komponentov UF-obluchennykh molekul i élektroforeticheskikh fraktsii karboksigemoglobina cheloveka.

The contribution of hem and globin components of electrophoretic fractions of UV-irradiated human carboxyhemoglobin to photodestruction of the protein was studied. The changes observed are the result of summation of some processes unequal in intensity and direction that take place in microheterogeneous media of photomodified protein. Photosensitivity of hemoproteid in electrophoretic fraction depends on apoprotein condition, whereas the hem photoresistance cannot be the evidence of the photostability of the whole molecule.

Evaluation of capillary zone electrophoresis assessment of beta proteins.

OBJECTIVE: Evaluate capillary zone electrophoresis for analyzing beta proteins for concentrations of transferrin and complement. DESIGN: Thirty normal sera were used to establish expected ranges for these proteins by re-gating on the specific peaks from the original histograms. A total of 61 sera with elevated beta proteins were evaluated by this method. An additional 50 sera with an acute phase reaction were evaluated. SETTING: All tests were done at Baptist Regional Laboratories on a Beckman CZE/1000 2000 instrument. PATIENTS OR OTHER PARTICIPANTS: Sera were taken from excess sera used for clinical testing. Thirty normal serum donors were tested. The 61 sera with elevated beta proteins were evaluated on a prospective basis following clinical testing. The 50 sera with acute phase patterns were evaluated retrospectively following clinical testing. INTERVENTION: None RESULTS: Among the 61 sera with increased beta protein, 34 (56%) had elevated transferrin but 57 (93%) had elevated complement levels. In the 50 sera from the acute phase reactant group, 24 sera had elevated complement. OUTCOME: The study showed that capillary zone electrophoresis could effectively be used to evaluate specific levels of transferrin and complement without further testing. CONCLUSIONS: These findings show that with this method, transferrin and complement can be quantitatively measured without further analysis and that the majority of beta protein increases are due to elevated complement levels in our population.

The prevalence of sickle cell trait in Sierra Leone. A laboratory profile.

Three thousand five hundred and twenty four (1527 male and 1997 female) samples were screened for the presence of the abnormal haemoglobin--Sickle Cell (HbS) between 1990-1993. 780 (22%) of these show sickle erythrocytes in a reduced oxygen environment. Electrophoretic differentiation of 344 samples positive from the metabisulphite screening test, revealed that 76 are of the homozygous form with 3 being HbSC. Noting the adverse consequences on the health status of those affected and the expense involved in the management of such patients, there is an urgent need for intervention.

Rapid capillary electrophoretic analysis of human serum proteins: qualitative comparison with high-throughput agarose gel electrophoresis.

This study details the qualitative results from a comparative evaluation of agarose gel electrophoresis (AGE) and (CZE) as a screening procedure for monoclonal proteins in serum. Three hundred and five serum samples were analyzed by the two techniques; samples suspected of containing monoclonal proteins based on abnormalities observed with AGE or CZE were confirmed by immunoelectrophoresis and/or immunofixation. CZE separation conditions were simple (requiring only a bare silica capillary and 150 mM borate buffer, pH 10.0) and separation was complete in under 120 s. The results obtained by CZE were comparable or better than those obtained with AGE. Samples displaying "point-of-application" artifacts on AGE were not problematic by CZE analysis; an abnormal profile, due to the presence of a monoclonal protein, or a normal profile were clearly observable. The rapid analysis, excellent reproducibility, automation and relatively high throughput (approximately 90 samples per 8 h on a single instrument) sets the stage for CZE analysis of serum proteins to be used routinely in a clinical setting.