The Case ∣ Renal failure in a male with Waldenström's macroglobulinemia

Zamkanei

et al. 2016

World J Nephrol Urol

Chronic kidney disease (CKD) is a major public health problem. Estimated glomerular filtration rates based on serum creatinine values are used to diagnose this condition, and accuracy of laboratory testing is a crucial step in diagnosing and managing these patients efficiently in a timely manner. Spuriously elevated creatinine values have been reported due to the interference of other substances, including paraproteins. Paraproteins can interfere with the determination of various clinically important analytes in an unpredictable manner. While mild to moderate degrees of interference affecting the measurement of serum creatinine values have been previously reported, we present a case of a patient with markedly elevated serum creatinine who was referred for emergent assessment for possible consideration of renal replacement therapy. A thorough history and repeat laboratory investigations at several laboratories ultimately revealed the initial serum creatinine level to be spuriously high, i.e. "pseudohypercreatinimea" due to immunoglobulin interference. Further investigations ultimately led to the diagnosis of Waldenstrom's macroglobulinemia and the patient was appropriately treated. However, this case sheds light on the importance of being aware of a spuriously high creatinine value and its possible causes, as it can have significant diagnostic implications.

Section: Discussioncontrasting

confidence: 38%

Section: Introductionmentioning

confidence: 99%

Pseudohypercreatininemia as an Initial Presentation of Waldenstrom’s Macroglobulinemia

Zamkanei

et al. 2016

World J Nephrol Urol

J of Clinical Apheresis

“…The vast majority of Myelomas produce IgG. Waldenström's is an eponym given for IgM myeloma [8]. The distribution of immuneglobulins is shown on Table III.…”

Section: Casementioning

confidence: 99%

Therapeutic apheresis: When things go wrong

Torloni

Lumadue

Zubair

2012

Therapeutic apheresis medicine requires in-depth knowledge of physiology, disease mechanisms as well as a thorough understanding of the parameters that can be adjusted in the instrument that are used. We report two cases where critical decision making was crucial during management of patients being treated with therapeutic apheresis. Case 1 involves an adult patient with severe circulating cryoglobulins and Case 2 describes a patient with Waldenström's macroglobulinemia and hyperviscosity. Both cases demonstrate the importance of readily available expert supervision of therapeutic apheresis procedures.

Practical Laboratory Medicine

“…Besides a few systematic studies—such as paraprotein interference with the measurement of total and direct bilirubin and high density lipoprotein cholesterol (HDL-C) on two automated chemistry analyzers using 88 samples with paraproteins [1] , and the study of interference with a direct bilirubin assay using 117 samples containing paraproteins [2] —the majority of these reports described specific cases of either IgM, IgG, or IgA paraprotein interference with various laboratory tests. There have been several reports of IgM paraprotein interference with albumin [3] , glucose [4] , [5] , C-reactive protein [6] , uric acid [7] , HDL-C [8] , [9] , [10] , total bilirubin [8] , [11] , phosphate [5] , creatinine [12] , [13] , [14] , [15] , calcium [16] , and total protein [17] , [18] , [19] . Interestingly, each of these cases described individual IgM paraprotein interferences with a particular assay on a particular platform.…”

Section: Introductionmentioning

confidence: 99%

“…When other samples containing IgM paraproteins were tested with the same assay, the interferences were typically not observed. When the original samples were tested on different platforms, the interference may or may not be observed [8] , [11] , [13] , [14] , [15] . In some reports, the interference was believed to be caused by the precipitation of paraproteins under assay conditions [1] , [2] , [5] , [11] .…”

Section: Introductionmentioning

confidence: 99%

The pH of chemistry assays plays an important role in monoclonal immunoglobulin interferences

Alberti

Drake

Song

2015

ObjectivesImmunoglobulin paraproteins can interfere with multiple chemistry assays. We want to investigate the mechanisms of immunoglobulin interference.Design and methodsSerum samples containing paraproteins from the index patient and eight additional patients were used to investigate the interference with the creatinine and total protein assays on the Beckman Coulter AU5400/2700 analyzer, and to determine the effects of pH and ionic strength on the precipitation of different immunoglobulins in these patient samples.ResultsThe paraprotein interference with the creatinine and total protein assays was caused by the precipitation of IgM paraprotein in the index patient's samples under alkaline assay conditions. At extremely high pH (12–13) and extremely low pH (1–2) and low ionic strength, paraprotein formed large aggregates in samples from the index patient but not from other patients.ConclusionsThe pH and ionic strength are the key factors that contribute to protein aggregation and precipitation which interfere with the creatinine and total protein measurements on AU5400/2700. The different amino acid sequence of each monoclonal paraprotein will determine the pH and ionic strength at which the paraprotein will precipitate.