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UnderstandingandInterpretingtheSerumProteinElectrophoresisAmericanFamilyPhysician

UnderstandingandInterpretingSerumProteinElectrophoresis
THEODOREX.OCONNELL,M.D.,TIMOTHYJ.HORITA,M.D.,andBARSAMKASRAVI,M.D.,KaiserPermanenteWoodlandHillsFamilyMedicineResidency
Program,WoodlandHills,California
AmFamPhysician.2005Jan171(1):105112.
Serumproteinelectrophoresisisusedtoidentifypatientswithmultiplemyelomaandotherserumproteindisorders.Electrophoresisseparates
proteinsbasedontheirphysicalproperties,andthesubsetsoftheseproteinsareusedininterpretingtheresults.Plasmaproteinlevelsdisplay
reasonablypredictablechangesinresponsetoacuteinflammation,malignancy,trauma,necrosis,infarction,burns,andchemicalinjury.A
homogeneousspikelikepeakinafocalregionofthegammaglobulinzoneindicatesamonoclonalgammopathy.Monoclonalgammopathiesare
associatedwithaclonalprocessthatismalignantorpotentiallymalignant,includingmultiplemyeloma,Waldenstrmsmacroglobulinemia,solitary
plasmacytoma,smolderingmultiplemyeloma,monoclonalgammopathyofundeterminedsignificance,plasmacellleukemia,heavychaindisease,and
amyloidosis.ThequantityofMprotein,theresultsofbonemarrowbiopsy,andothercharacteristicscanhelpdifferentiatemultiplemyelomafromthe
othercausesofmonoclonalgammopathy.Incontrast,polyclonalgammopathiesmaybecausedbyanyreactiveorinflammatoryprocess.
Serumproteinelectrophoresisisalaboratoryexaminationthatcommonlyisusedtoidentifypatientswithmultiplemyelomaandotherdisordersofserumprotein.
Manysubspecialistsincludeserumproteinelectrophoresisscreeningintheinitialevaluationfornumerousclinicalconditions.Sometimes,however,theresultsof
thisexaminationcanbeconfusingordifficulttointerpret.
Thisarticleprovidesacomprehensivereviewofserumproteinelectrophoresis,includingadiscussionofhowtheexaminationisperformed,whatitmeasures,and
whenitisindicated.Thearticlealsoprovidesasimpleguidetoresultinterpretationandsuggestionsonfollowupofabnormalresults.

Definitions
Electrophoresisisamethodofseparatingproteinsbasedontheirphysicalproperties.Serumisplacedonaspecificmedium,andachargeisapplied.Thenet
charge(positiveornegative)andthesizeandshapeoftheproteincommonlyareusedindifferentiatingvariousserumproteins.1
Severalsubsetsofserumproteinelectrophoresisareavailable.Thenamesofthesesubsetsarebasedonthemethodthatisusedtoseparateanddifferentiatethe
variousserumcomponents.Inzoneelectrophoresis,forexample,differentproteinsubtypesareplacedinseparatephysicallocationsonagelmadefromagar,
cellulose,orotherplantmaterial.2,3Theproteinsarestained,andtheirdensitiesarecalculatedelectronicallytoprovidegraphicaldataontheabsoluteandrelative
amountsofthevariousproteins.Furtherseparationofproteinsubtypesisachievedbystainingwithanimmunologicallyactiveagent,whichresultsin
immunofluorescenceandimmunofixation.

ComponentsofSerumProteinElectrophoresis
Thepatternofserumproteinelectrophoresisresultsdependsonthefractionsoftwomajortypesofprotein:albuminandglobulins.Albumin,themajorprotein
componentofserum,isproducedbytheliverundernormalphysiologicconditions.Globulinscompriseamuchsmallerfractionofthetotalserumproteincontent.
Thesubsetsoftheseproteinsandtheirrelativequantityaretheprimaryfocusoftheinterpretationofserumproteinelectrophoresis.1,3
Albumin,thelargestpeak,liesclosesttothepositiveelectrode.Thenextfivecomponents(globulins)arelabeledalpha1,alpha2,beta1,beta2,andgamma.The
peaksforthesecomponentslietowardthenegativeelectrode,withthegammapeakbeingclosesttothatelectrode.Figure1showsatypicalnormalpatternforthe
distributionofproteinsasdeterminedbyserumproteinelectrophoresis.
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Figure1
Typicalnormalpatternforserumproteinelectrophoresis.

ALBUMIN
Thealbuminbandrepresentsthelargestproteincomponentofhumanserum.Thealbuminlevelisdecreasedundercircumstancesinwhichthereisless
productionoftheproteinbytheliverorinwhichthereisincreasedlossordegradationofthisprotein.Malnutrition,significantliverdisease,renalloss(e.g.,in
nephroticsyndrome),hormonetherapy,andpregnancymayaccountforalowalbuminlevel.Burnsalsomayresultinalowalbuminlevel.Levelsofalbuminare
increasedinpatientswitharelativereductioninserumwater(e.g.,dehydration).

ALPHAFRACTION
Movingtowardthenegativeportionofthegel(i.e.,thenegativeelectrode),thenextpeaksinvolvethealpha1andalpha2components.Thealpha1proteinfractionis
comprisedofalpha1antitrypsin,thyroidbindingglobulin,andtranscortin.Malignancyandacuteinflammation(resultingfromacutephasereactants)canincrease
thealpha1proteinband.Adecreasedalpha1proteinbandmayoccurbecauseofalpha1antitrypsindeficiencyordecreasedproductionoftheglobulinasaresultof
liverdisease.Ceruloplasmin,alpha2macroglobulin,andhaptoglobincontributetothealpha2proteinband.Thealpha2componentisincreasedasanacutephase
reactant.

BETAFRACTION
Thebetafractionhastwopeakslabeledbeta1andbeta2.Beta1iscomposedmostlyoftransferrin,andbeta2containsbetalipoprotein.IgA,IgM,andsometimes
IgG,alongwithcomplementproteins,alsocanbeidentifiedinthebetafraction.

GAMMAFRACTION
Muchoftheclinicalinterestisfocusedonthegammaregionoftheserumproteinspectrumbecauseimmunoglobulinsmigratetothisregion.Itshouldbenotedthat
immunoglobulinsoftencanbefoundthroughouttheelectrophoreticspectrum.Creactiveprotein(CRP)islocatedintheareabetweenthebetaandgamma
components.1

Indications
Serumproteinelectrophoresiscommonlyisperformedwhenmultiplemyelomaissuspected.Theexaminationalsoshouldbeconsideredinotherredflag
situations(Table1).24
View/PrintTable

TABLE1
IndicationsforSerumProteinElectrophoresis
Suspectedmultiplemyeloma,Waldenstrmsmacroglobulinemia,primaryamyloidosis,orrelateddisorder
Unexplainedperipheralneuropathy(notattributedtolongstandingdiabetesmellitus,toxinexposure,chemotherapy,etc.)
Newonsetanemiaassociatedwithrenalfailureorinsufficiencyandbonepain
Backpaininwhichmultiplemyelomaissuspected
Hypercalcemiaattributedtopossiblemalignancy(e.g.,associatedweightloss,fatigue,bonepain,abnormalbleeding)
Rouleauxformationsnotedonperipheralbloodsmear
Renalinsufficiencywithassociatedserumproteinelevation
Unexplainedpathologicfractureorlyticlesionidentifiedonradiograph

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BenceJonesproteinuria

Informationfromreferences2through4.

Iftheexaminationisnormalbutmultiplemyeloma,Waldenstrmsmacroglobulinemia,primaryamyloidosis,orarelateddisorderstillissuspected,immunofixation
alsoshouldbeperformedbecausethistechniquemaybemoresensitiveinidentifyingasmallmonoclonal(M)protein.5

InterpretationofResults
Plasmaproteinlevelsdisplayreasonablypredictablechangesinresponsetoacuteinflammation,malignancy,trauma,necrosis,infarction,burns,andchemical
injury.Thissocalledacutereactionproteinpatterninvolvesincreasesinfibrinogen,alpha1antitrypsin,haptoglobin,ceruloplasmin,CRP,theC3portionof
complement,andalpha1acidglycoprotein.Often,thereareassociateddecreasesinthealbuminandtransferrinlevels.6Table26listscharacteristicpatternsof
acutereactionproteinsfoundonserumproteinelectrophoresis,alongwithassociatedconditionsordisorders.
View/PrintTable

TABLE2
CharacteristicPatternsofAcuteReactionProteinsFoundonSerumProteinElectrophoresisandAssociatedConditionsor
Disorders
Increasedalbumin

Increasedbeta1orbeta2globulins

Dehydration

Biliarycirrhosis

Decreasedalbumin

Carcinoma(sometimes)

Chroniccachecticorwastingdiseases

Cushingsdisease

Chronicinfections

Diabetesmellitus(somecases)

Hemorrhage,burns,orproteinlosingenteropathies

Hypothyroidism

Impairedliverfunctionresultingfromdecreasedsynthesisofalbumin

Irondeficiencyanemia

Malnutrition

Malignanthypertension

Nephroticsyndrome

Nephrosis

Pregnancy

Polyarteritisnodosa

Increasedalpha1 globulins

Obstructivejaundice

Pregnancy

Thirdtrimesterpregnancy

Decreasedalpha1globulins

Decreasedbeta1orbeta2globulins

Alpha1antitrypsindeficiency

Proteinmalnutrition

Increasedalpha2globulins

Increasedgammaglobulins

Adrenalinsufficiency

Amyloidosis

Adrenocorticosteroidtherapy

Chronicinfections(granulomatousdiseases)

Advanceddiabetesmellitus

Chroniclymphocyticleukemia

Nephroticsyndrome

Cirrhosis

Decreasedalpha2globulins

Hodgkinsdisease

Malnutrition

Malignantlymphoma

Megaloblasticanemia

Multiplemyeloma

Proteinlosingenteropathies

Rheumatoidandcollagendiseases(connectivetissuedisorders)

Severeliverdisease

Waldenstrmsmacroglobulinemia

Wilsonsdisease

Decreasedgammaglobulins

Intheinterpretationofserumproteinelectrophoresis,mostattentionfocusesonthegammaregion,whichiscomposedpredominantlyofantibodiesoftheIgGtype.
Thegammaglobulinzoneisdecreasedinhypogammaglobulinemiaandagammaglobulinemia.Diseasesthatproduceanincreaseinthegammaglobulinlevel
includeHodgkinsdisease,malignantlymphoma,chroniclymphocyticleukemia,granulomatousdiseases,connectivetissuediseases,liverdiseases,multiple
myeloma,Waldenstrmsmacroglobulinemia,andamyloidosis.3,7
Althoughmanyconditionscancauseanincreaseinthegammaregion,severaldiseasestatescauseahomogeneousspikelikepeakinafocalregionofthe
gammaglobulinzone(Figure2).Thesesocalledmonoclonalgammopathiesconstituteagroupofdisordersthatarecharacterizedbyproliferationofasingle
cloneofplasmacellsthatproduceahomogeneousMprotein.6
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Figure2
Abnormalserumproteinelectrophoresispatterninapatientwithmultiplemyeloma.Notethelargespikeinthegammaregion.

MonoclonalVersusPolyclonalGammopathies
Itisextremelyimportanttodifferentiatemonoclonalfrompolyclonalgammopathies.Monoclonalgammopathiesareassociatedwithaclonalprocessthatis
malignantorpotentiallymalignant.Incontrast,polyclonalgammopathiesmaybecausedbyanyreactiveorinflammatoryprocess,andtheyusuallyareassociated
withnonmalignantconditions.ThemostcommonconditionsinthedifferentialdiagnosisofpolyclonalgammopathyarelistedinTable3.8,9
View/PrintTable

TABLE3
DifferentialDiagnosisofPolyclonalGammopathy
INFECTIONS

MALIGNANCIES

Viralinfections,especiallyhepatitis,humanimmunodeficiencyvirusinfection,
mononucleosis,andvaricella

Solidtumors

Focalorsystemicbacterialinfections,includingendocarditis,osteomyelitis,and
bacteremia

Lungcancer

Tuberculosis
Connectivetissuediseases
Systemiclupuserythematosus
Mixedconnectivetissue
Temporalarteritis
Rheumatoidarthritis
Sarcoid
Liverdiseases
Cirrhosis
Ethanolabuse
Autoimmunehepatitis

Ovariantumors
Hepatocellularcancer
Renaltumors
Gastrictumors
Hematologiccancers(seebelow)
Hematologicandlymphoproliferativedisorders
Lymphoma
Leukemia
Thalassemia
Sicklecellanemia
Otherinflammatoryconditions
Gastrointestinalconditions,includingulcerativecolitisandCrohnsdisease

Viralinducedhepatitis

Pulmonarydisorders,includingbronchiectasis,cysticfibrosis,chronicbronchitis,
andpneumonitis

Primarybiliarycirrhosis

Endocrinediseases,includingGravesdiseaseandhashimotosthyroiditis

Primarysclerosingcholangitis

Informationfromreferences8and9.

AnMproteinischaracterizedbythepresenceofasharp,welldefinedbandwithasingleheavychainandasimilarbandwithakappaorlambdalightchain.A
polyclonalgammopathyischaracterizedbyabroaddiffusebandwithoneormoreheavychainsandkappaandlambdalightchains.7
Onceamonoclonalgammopathyisidentifiedbyserumproteinelectrophoresis,multiplemyelomamustbedifferentiatedfromothercausesofthistypeof
gammopathy.AmongtheseothercausesareWaldenstrmsmacroglobulinemia,solitaryplasmacytoma,smolderingmultiplemyeloma,monoclonalgammopathyof
undeterminedsignificance,plasmacellleukemia,heavychaindisease,andamyloidosis.4,7
ThequantityofMproteincanhelpdifferentiatemultiplemyelomafrommonoclonalgammopathyofundeterminedsignificance.Definitivediagnosisofmultiple
myelomarequires10to15percentplasmacellinvolvementasdeterminedbybonemarrowbiopsy.Characteristicdifferentiatingfeaturesofthemonoclonal
gammopathiesarelistedinTable4.7

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View/PrintTable

TABLE4
CharacteristicFeaturesofMonoclonalGammopathies
DISEASE
Multiplemyeloma

DISTINCTIVEFEATURES
Mproteinappearsasanarrowspikeinthegamma,beta,oralpha2regions.
Mproteinlevelisusuallygreaterthan3gperdL.
Skeletallesions(e.g.,lyticlesions,diffuseosteopenia,vertebralcompressionfractures)arepresentin80percentof
patients.
Diagnosisrequires10to15percentplasmacellinvolvementonbonemarrowbiopsy.
Anemia,pancytopenia,hypercalcemia,andrenaldiseasemaybepresent.

Monoclonalgammopathyofundetermined
significance

Mproteinlevelislessthan3gperdL.

Thereislessthan10percentplasmacellinvolvementonbonemarrowbiopsy.
AffectedpatientshavenoMproteinintheirurine,nolyticbonelesions,noanemia,nohypercalcemia,andnorenal
disease.
Smolderingmultiplemyeloma

Mproteinlevelisgreaterthan3gperdL.
Thereisgreaterthan10percentplasmacellinvolvementonbonemarrowbiopsy.
Affectedpatientshavenolyticbonelesions,noanemia,nohypercalcemia,andnorenaldisease.

Plasmacellleukemia

Peripheralbloodcontainsmorethan20percentplasmacells.

Insomepatientswithaplasmacelldyscrasia,serumproteinelectrophoresismaybenormalbecausethecompletemonoclonalimmunoglobulinisabsentoris
presentataverylowlevel.7Inoneseries,6serumproteinelectrophoresisshowedaspikeorlocalizedbandinonly82percentofpatientswithmultiplemyeloma.
Theremainderhadhypogammaglobulinemiaoranormalappearingpattern.Consequently,urineproteinelectrophoresisisrecommendedinallpatientssuspected
ofhavingaplasmacelldyscrasia.10
AnadditionalpointtoconsideristhesizeoftheMproteinspike.Althoughthisspikeisusuallygreaterthan3gperdLinpatientswithmultiplemyeloma,uptoone
fifthofpatientswiththistumormayhaveanMproteinspikeoflessthan1gperdL.10Hypogammaglobulinemiaonserumproteinelectrophoresisoccursinabout
10percentofpatientswithmultiplemyelomawhodonothaveaserumMproteinspike.11MostofthesepatientshavealargeamountofBenceJonesprotein
(monoclonalfreekappaorlambdachain)intheirurine.11Thus,thesizeoftheMproteinspikeisnothelpfulinexcludingmultiplemyeloma.
IfmultiplemyelomastillisconsideredclinicallyinapatientwhodoesnothaveanMproteinspikeonserumproteinelectrophoresis,urineproteinelectrophoresis
shouldbeperformed.

EvaluationofanAbnormalSerumProteinElectrophoresis
Monoclonalgammopathyispresentinupto8percentofhealthygeriatricpatients.12Allpatientswithmonoclonalgammopathyrequirefurtherevaluationto
determinethecauseoftheabnormality.Patientswithmonoclonalgammopathyofundeterminedsignificancerequireclosefollowupbecauseabout1percentper
yeardevelopmultiplemyelomaoranothermalignantmonoclonalgammopathy.13[EvidencelevelB,prospectivecohortstudy]Analgorithmforthefollowupof
patientswithamonoclonalgammopathyisprovidedinFigure3.6
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Figure3
Suggestedalgorithmforfollowupofamonoclonalgammopathy.(SPEP=serumproteinelectrophoresis)Informationfromreference6.

IftheserumMproteinspikeis1.5to2.5gperdL,itisimportanttoperformnephelometrytoquantifytheimmunoglobulinspresentandtoobtaina24hoururine
collectionforelectrophoresisandimmunofixation.Iftheseexaminationsarenormal,serumproteinelectrophoresisshouldberepeatedinthreetosixmonthsifthat
examinationisnormal,serumproteinelectrophoresisshouldberepeatedannually.Iftherepeatexaminationisabnormalorfuturepatternsareabnormal,thenext
stepistoreferthepatienttoahematologistoncologist.
AnMproteinspikeofgreaterthan2.5gperdLshouldbeassessedwithametastaticbonesurveythatincludesasingleviewofthehumeriandfemurs.Inaddition,
abeta2microglobulintest,aCRPtest,anda24hoururinecollectionforelectrophoresisandimmunofixationshouldbeperformed.IfWaldenstrms
macroglobulinemiaorotherlymphoproliferativeprocessissuspected,anabdominalcomputedtomographicscanandbonemarrowaspirationandbiopsyshouldbe
performed.Abnormalitiesinanyofthesetestsshouldresultinareferraltoahematologistoncologist.Ifalltestsarenormal,thepatternoffollowupinFigure36can
beundertaken.Ifserumproteinelectrophoresisisabnormalatanytimeduringthefollowup,areferralshouldbemade

TheAuthors showallauthorinfo
THEODOREX.OCONNELL,M.D.,isassociateprogramdirectoranddirectoroftheresearchcurriculumattheKaiserPermanenteWoodlandHills(Calif.)Family
MedicineResidencyProgram.HealsoisclinicalinstructorintheDepartmentofFamilyMedicineattheDavidGeffenSchoolofMedicineattheUniversityof
California,LosAngeles(UCLA).Dr.OConnellisapartnerphysicianwithSouthernCaliforniaPermanenteMedicalGroup,WoodlandHills.Hereceivedhismedical
degreefromUCLASchoolofMedicineandcompletedafamilymedicineresidencyandchiefresidencyatSantaMonicaUCLAMedicalCenter....

REFERENCES showallreferences
1.JacobyRF,ColeCE.Moleculardiagnosticmethodsincancergenetics.In:AbeloffMD,etal.,eds.Clinicaloncology.2ded.NewYork:ChurchillLivingstone,

2000:11921....

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