Homework SourseA 60yearold woman with a history of rheumatoid arthritis smo
A 60-year-old woman with a history of rheumatoid arthritis, smoking of 60 packs/year, chronic obstructive pulmonary disease, and treated hypertension underwent a screening colonoscopy and then felt poorly for a week. She saw her family physician, who referred her to the local hospital clinic, where they did the test listed in the table below. Laboratory results Test Results Reference Range Creatinine 3.7 mg/dL Women <1.2 mg/dL BUN 35 mg/dL 5-20 mg/dL Creatinine clearance 12.5 mL/min 75-115 mL/min C3 148 mg/dL 80-200 mg/dL C4 19 mg/dL 15-80 mg/dL Albumin 4.1 g/dL 3.5 – 5.0 g/dL Calcium 9 mg/dL 8-10 mg/dL Phosphorus 4.6 mg/dL 2.5 – 4.5 mg/dL Cryoglobulin screen negative Serum protein electrophoresis – polyclonal hypergammaglobulinemia with no monoclonal immunoglobulin spike identified. Urine protein electrophoresis – protein 15.9 mg/dL with normal immunofixation electrophoresis Urine sediment - no RBCs, 4 – 8 WBCs/hpf, granular and hyaline casts Her creatinine and BUN levels 2 weeks after the colonoscopy were 4.6 and 46 mg/dL, respectively; a baseline (from previous physician’s office testing) serum creatinine was 0.9 mg/dL. Laboratory results are show 1. What disease state is the most likely explanation for the patient’s laboratory results? 2. What is the significance of the polyclonal hypergammaglobulinemia with no monoclonal immunoglobulin spike identified on SPE? 3. Is the patient’s urine protein normal? 4. Describe the immunofixation electrophoresis method.
Solution
A 60-year-old woman with a history of rheumatoid arthritis,
smoking of 60 packs/year,
chronic obstructive pulmonary disease,
and treated hypertension
underwent a screening colonoscopy and then felt poorly for a week.
She saw her family physician, who referred her to the local hospital clinic, where they did the test listed in the table below. ‘
Laboratory results Test Results Reference Range
Range for Women
Inference from the result and range
Creatinine 3.7 mg/dL
<1.2 mg/dL
Creatinine is a waste molecule generated from muscle metabolism Too much high.
This test is done to know the Function of Kidney
A higher levels may be due to:
· urinary tract Blockage
·
· Kidney problems, like kidney damage or failure, infection, or may be due to reduced blood flow
·
· Loss of body fluid (dehydration) or due to Muscle problems, such as breakdown of muscle fibers
BUN 35 mg/dL
5-20 mg/dL
Blood Urea Nitrogen Too much high
This test is done to know the Function of Kidney If kidneys are unable to remove urea from the blood then BUN level rises
A higher levels may be due to:
Heart failure,
dehydration, or a diet high in protein
Creatinine clearance 12.5 mL/min
75-115 mL/min
Too much low…..If serum creatinine is elevated, creatinine clearance is low.
Causes for low creatinine clearance levels.
Kidney damage, blood flow to the kidneys, or urinary tract blockage.
heart failure and dehydration
C3 148 mg/dL
80-200 mg/dL
Normal in range
C4 19 mg/dL
15-80 mg/dL
Normal in range
Albumin 4.1 g/dL URINE
3.5 – 5.0 g/dL
Normal in range
Albumin proteins keep the blood from leaking out of blood vessels and are important for tissue growth/healing
Calcium 9 mg/dL
8-10 mg/dL
Normal in range
Phosphorus 4.6 mg/dL
2.5 – 4.5 mg/dL
Border
Cryoglobulin screen
negative
Serum protein electrophoresis polyclonal (SPEP)
hypergammaglobulinemia with no monoclonal immunoglobulin spike identified
Negative for M- Protein spike. So No multiple myeloma and other serum protein disorders.
Urine protein electrophoresis – protein (UPEP)
5.9 mg/dL with normal immunofixation electrophoresis
1-14 mg/dl
This test is generally performed on a single urine sample. Bence-Jones proteins will be detected if present. A routine urinalysis will not detect Bence-Jones proteins.
Urine sediment
no RBCs,
4 – 8 WBCs/hpf, granular and hyaline casts
3.2-10.6
In Normal range
2 weeks after the colonoscopy
creatinine -4.6 mg/dL,
BUN levels- 46 mg/dL,
Increased further too high levels
serum creatinine
0.9 mg/dL.
Based on the lab results : That woman is suffering with nephrocalcinosis
2. What is the significance of the polyclonal hypergammaglobulinemia with no monoclonal immunoglobulin spike identified on SPE?
This test SPEP is used to identify patients with multiple myeloma and other serum protein disorders. Here polyclonal hypergammaglobulinemia with no monoclonal immunoglobulin spike identified on SPE. So Serum M- Protein spike is not found. So No multiple myeloma and other serum protein disorders.
3.Is the patient’s urine protein normal?
Yes. Urine protein electrophoresis – protein (UPEP) 5.9 mg/dL with normal immunofixation electrophoresis
4. Describe the immunofixation electrophoresis method.
Immunofixation electrophoresis (IFE): It is a method used for the identification of proteins within complex mixtures after separation by either conventional zone electrophoresis or isoelectric focusing.
The antigens are separated by electrophoresis most commonly and precipitated with specific antibodies in situ. Where the immunoglobulins with specific reactivity can be also precipitated with the proper antigens after electrophoresis in reverse or reversed IFE.
All this is because of its great versatility, potentially high sensitivity, ease to perform and customize, and relatively low cost with no requirement for expensive instrumentation, manual IFE remains a valuable tool for both clinical diagnostic testing and research. If proper antibodies are available -low-viscosity body fluid specimen or, possibly, culture fluid could also be tested using IFE .
After pretreatment with chaotropic and/or reducing agents, even high-viscosity specimens might be amenable to testing with IFE.
| Range for Women | Inference from the result and range | ||
| Creatinine 3.7 mg/dL | <1.2 mg/dL | Creatinine is a waste molecule generated from muscle metabolism Too much high. This test is done to know the Function of Kidney | A higher levels may be due to: · urinary tract Blockage · · Kidney problems, like kidney damage or failure, infection, or may be due to reduced blood flow · · Loss of body fluid (dehydration) or due to Muscle problems, such as breakdown of muscle fibers |
| BUN 35 mg/dL | 5-20 mg/dL | Blood Urea Nitrogen Too much high This test is done to know the Function of Kidney If kidneys are unable to remove urea from the blood then BUN level rises | A higher levels may be due to: Heart failure, dehydration, or a diet high in protein |
| Creatinine clearance 12.5 mL/min | 75-115 mL/min | Too much low…..If serum creatinine is elevated, creatinine clearance is low. | Causes for low creatinine clearance levels. Kidney damage, blood flow to the kidneys, or urinary tract blockage. heart failure and dehydration |
| C3 148 mg/dL | 80-200 mg/dL | Normal in range | |
| C4 19 mg/dL | 15-80 mg/dL | Normal in range | |
| Albumin 4.1 g/dL URINE | 3.5 – 5.0 g/dL | Normal in range | Albumin proteins keep the blood from leaking out of blood vessels and are important for tissue growth/healing |
| Calcium 9 mg/dL | 8-10 mg/dL | Normal in range | |
| Phosphorus 4.6 mg/dL | 2.5 – 4.5 mg/dL | Border | |
| Cryoglobulin screen | negative | ||
| Serum protein electrophoresis polyclonal (SPEP) | hypergammaglobulinemia with no monoclonal immunoglobulin spike identified | Negative for M- Protein spike. So No multiple myeloma and other serum protein disorders. | |
| Urine protein electrophoresis – protein (UPEP) 5.9 mg/dL with normal immunofixation electrophoresis | 1-14 mg/dl | This test is generally performed on a single urine sample. Bence-Jones proteins will be detected if present. A routine urinalysis will not detect Bence-Jones proteins. | |
| Urine sediment | no RBCs, | ||
| 4 – 8 WBCs/hpf, granular and hyaline casts | 3.2-10.6 | In Normal range | |
| 2 weeks after the colonoscopy creatinine -4.6 mg/dL, BUN levels- 46 mg/dL, | Increased further too high levels | ||
| serum creatinine | 0.9 mg/dL. |
