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Abstract
The monoclonal gammopathies are a group of disorders characterized by the proliferation of a single clone of plasma cells that produces a homogenous monoclonal M protein.
Each M protein consists of two heavy polypeptide chains of the same class: gamma (γ) constitutes immunoglobulin G (IgG), alpha (α) found in IgA, mu (μ) is present in IgM, delta (δ) occurs in IgD, and IgE is characterized by (ε). Two light polypeptide chains {either kappa (κ) or lambda (λ)} of the same type are found in each M protein.
Monoclonal gammopathies are generally diseases of the elderly, with a median age of onset of over 70 years. The monoclonal protein is the result of an underlying malignancy and is associated with evidence of disease infiltrating lymph nodes, liver, spleen, bone, or other organs (eg, multiple myeloma, solitary plasmacytoma, Waldenstrom’s macroglobulinemia). In other cases, the monoclonal protein is the result of a small limited clonal expansion, and causes no symptoms (eg, monoclonal gammopathy of undetermined significance, MGUS).
The aim of the present study was:
- To study the prevalence of monoclonal gammopathy by serum protein electrophoresis in the elderly population (>65years) in Alexandria.
The present study was carried out on 600 elderly persons (age >65 years): (after obtaining a written informed consent from each patient) with exclusion of patients previously diagnosed or known to have myeloma, Waldenstrom’s macroglobulinaemia, Non Hodgkin lymphoma, heavy chain disease, or any other cause of monoclonal gammopathy.
The studied subjects were subjected to the following investigations:
• Complete blood picture.
• Erythrocyte sedimentation rate (ESR).
• Complete urine analysis.
• Liver function tests :
- Serum alanine transaminase (ALT).
- Serum aspartate transaminase (AST).
- Serum albumin.
- Prothrombin activity.
• Renal function tests :
- Serum creatinine.
- Blood urea.
- Serum uric acid.
• Serum protein electrophoresis: patients who had positive M- band were subjected to the following investigations to diagnose the cause of the monoclonal gammopathy:
• Serum calcium.
• Serum LDH.
• CRP.
• Serum 2 microglobulin.
• Bone marrow aspiration and/or trephine biopsy.
• 24 hrs Urinary collection to detect Bence Jones proteins.
• Lymph node biopsy if needed.
• Serum protein electrophoresis quantification by nephelometry (IgM and IgG).
• Radiology (skeletal survey, CT, MRI and abdominal US).
The results of this study disclosed the following:
• Among the studied elderly persons (600 persons) 3.7% had a positive monoclonal gammopathy.
• The mean age of the persons who had positive monoclonal gammopathy was 69.13 ± 3.634 years, with male predominance as 59.1% of them were males.
• Among the studied 22 patients, multiple myeloma constituted 77.3%, MGUS 13.7%, WM 4.5% and PCL4.5%.
• 40.9% of monoclonal gammopathies patients in the present study had elevated IgG levels, 22.7% had elevated IgM and the remaining patients had normal levels of both IgG and IgM.
• Among multiple myeloma patients (17 patients) 23.5% had positive Benes-Jones proteinuria, 47.1% had osteolytic lesions, 29.4% had hypercalcemia, 58.8% had elevated levels of serum B2 microglobulin, 41.2% had hypoalbuminemia and 23.5% had disturbed renal functions.
• According to ISS 17.6% of multiple myeloma patients were in stage I, 52.9% was in stage II and 29.5% was in stage III.
• The relation ISS and B2 microglobulin was statistically significant (p= 0.000).
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We recommended that:
• Serum protein electrophoresis (SPEP) should be included as a routine investigation for elderly persons to discover the monoclonal gammopathies early, especially those with a markedly elevated ESR.
• Using more sensitive laboratory methods as immunofixation, it allows detection of smaller amount of M protein.
• Long term follow up of MGUS patients because they have a risk of developing malignant plasma cell disorder in about 1/3 of cases.
• Further studies should be carried out on larger number of persons and in different areas allover Egypt.
• Further studies should be conductd in other age groups because monoclonal gammopathies can occur in younger persons.
• Extension of the study to more researches needed for each subtype of monoclonal gammopathies and their prevalence.