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1

What lab value may be increased postprandially in people that are Lewis positive group B or O secretors?

Alkaline phosphatase (intestinal)

Medications (OCPs, NSAIDs) may elevate Alk Phos levels

2

Which liver disease:

1) is associated with marked polyclonal increase in IgG?

2) is associated with marked polyclonal increase in IgM?

1) Autoimmune hepatitis

2) Primary biliary cirrhosis

3

What are reasons for decreased albumin on SPEP?

Malnourishment (used to assess nutritional status)

Inflammatory states (negative acute phase reactant)

Liver disease

Increased catabolism: inc T4, pregnancy or steroids

Loss: nephrosis, burn, protein losing enteropathy

Fluid retention (SIADH)

4

What are reasons for increased or decreased alpha 1 band on SPEP?

Increased: Acute inflammatory states (acute phase reactant)

Decreased: alpha 1 anti-trypsin deficiency, HDL def and aged serum

5

1) What are the reasons for increased alpha 2 band on SPEP?

2) What two other proteins are represented in the alpha 2 band?

1) Relative concentration elevated in liver and renal disease; large size prevents its loss in nephrotic syndrome leading to a relative 10 fold rise in concentration

2) Ceruloplasmin (decreased in Wilson's disease, acute phase reactant) and Haptoglobin (binds free hemoglobin, acute phase reactant)

*NOTE low ceruloplasmin is not detectable with SPEP

6

What major protein is represented in the beta 1 region and what would cause this spike to increase?

Transferrin

It is markedly increased in iron deficiency

7

What major proteins are represented in the beta 2 region?

IgA and C3

*Fibrinogen, usually absent from serum, may be present in the beta-gamma interface when there is incomplete clotting (a possible pseudo M spike)

8

What major proteins are represented in the gamma region (gamma 1 and gamma 2)?

Gamma 1: gamma globulins

Gamma 2: CRP (acute phase reactant)

*CRP normally 2-3 mg/L but high level CRP elevation (>10 mg/L) usually indicates active inflammation such as collagen vascular disease, infection, etc and low level CRP elevation (3-10 mg/dL) is indicative of cellular stress and correlated with higher all cause mortality, poor outcome following cardiovascular events

9

What does it mean if you see a bimodal albumin peak on SPEP?

This is seen in heterozygotes for albumin alleles

No clinical significance

10

What pattern would you see on SPEP in a patient with nephrotic syndrome?

Loss of small serum proteins, particularly albumin, while large proteins are retained

Result is a decrease in all bands except alpha 2 (too big so it's retained)

11

What pattern would you see on SPEP in a patient with acute inflammation?

Decreased albumin

Increased alpha 1 and alpha 2

Normal-to-increased gamma globulins

12

What condition causes beta gamma briding on SPEP?

Indicative of cirrhosis cause by increased serum IgA

Additional features include hypoalbuminemia and blunted alpha 1 and alpha 2 bands

13

If the basal triglyceride level is elevated, what two clinical scenarios can cause this "pseudo-hypertriglyceridemia"?

DKA
Glycerol kinase def.
- (glycerol –GK-- > glycerol-3-phosphate)

These people aren't metabolizing TGs correctly

14

What is Friedewald equation (which you MUST KNOW for boards)?

LDL-C = TC – HDL-C – Tg/5* (*estimates VLDL-C)

If TG >400, it is invald!

15

What is Osler guy's helpful tip for remembering the different lipid disorders and what is elevated in them?

Increased TG: Types I (chylomicrons), IV (VLDL) and V (chylomicrons and VLDL)

Increased LDL: Types IIA (LDL)

Increased TG and LDL: Types IIB (LDL and VLDL) and III (IDL and remanant lipoproteins

16

What are the causes of type I hyperlipidemia (chyolmicronemia)?

Lipoprotein Lipase Deficiency: AR, rare, onset in infancy

Apo CII Deficiency: ligand for lipoprotein lipase, AR, rare, onset in childhood

SLE: acquired, autoantibody against lipoprotein lipase

17

What are the acquired and genetic causes of type IV hyperlipemia (increased VLDL)?

Genetic

Insulin resistance: insulin receptor mutation, lipodystrophy

Familial hypertriglyceridemia

Familial combined hypertriglyceridemia 

Inborn errors of metabolism:glycogen storage disease

Acquired 

Insulin resistance: increased VLDL production, decreased VLDL clearance, decreased activity of LPL (includes obesity, met syn, diabetes, Cushing, acromegaly, pheo, steroids)

Liver disease

Renal disease

Hypothyroidism

18

What are the genetic causes of type IIA hyperlipemia and what particle is involved?

LDL

Monogenic disorders
Familial hypercholesteromia
Familial hyperapo-B-lipoproteinemia
AR familial hypercholesteromia
Familial combined hyperlipidemia
Polygenic disorders
Polygenic hypercholesterolemia

19

What are the acquired causes of type IIA hyperlipidemia and what particle is involved?

Liver disease (e.g.,biliary tract disease*)

*in biliary tract disease, there is a lipoprotein called LpX which can falsely elevate both LDL and HDL
Renal disease (e.g., nephrosis)
Endocrine (hypothyroidism, diabetes mellitus)
Drugs - glucocorticoids, androgens

20

What are the causes of type IIB hyperlipidemia and what are the particles involved?

LDL & VLDL

Similar to HLP IIA
except: Familial hyperapo-Blipoproteinemia: HLP IIA only
(no incr. in VLDL)

21

What are the causes and particles involved in type III hyperlipidemia?

LDL and remnant lipoproteins

Happens if somone is homozygous for Apo E2/E2 AND has an environmental stressor that makes them hyperlipidemic such as:
- EtOHism
- DM
- Renal disease
- Liver disease

22

What is the one genetic cause of low lipoproteins that you MUST KNOW for boards and how is it inherited, what particles are low and what are the clinical features?

Abetalipoproteinemia

Autosomal recessive failure of apo B production
- very low Tg & chol
- Very low: VLDL & LDL
HDL: preserved (lacks apo B)
Clinical: acanthocytes
developmental failure in infancy
fat malabsorption

23

What are the positive acute phase reactants?

C3, CRP
A1AT, A2M
Ceruloplasmin
Fibrinogen
Haptoglobin

24

What are the negative acute phase reactant?

Albumin
Transthyretin
Retinol binding protein (RBP)
Transferrin

25

What is the one body fluid where you can see a band in the pre-albumin peak on serum protein electrophoresis?

CSF

Also has a "2nd form" of beta which represents CSF transferrin

Hallmarks of CSF:

Prealbumin spike

Double transferrin (B1) peak from asialated transferrin aka Tau protein

26

What proteins are represented in the prealbumin peak on SPEP?

Retinal Binding Protein (RBP) which transports VitA

and

Transthyretin which is a T4 transporter

*prealbumin is an indicator of nutritional status (half like 48 hours) and is a neg acute phase reactant

27

What are significant causes of decreases in RBP or
transthyretin (which are seen in the pre-albumin peak on SPEP)?

RBP: malnutrition

Transthyretin: malnutrition and nephrosis

*why would nephrosis be a prothrombotic state if you are losing proteins? You are also losing anti-coag like antithrombin 3

28

What are reasons for increased albumin on SPEP?

Dehydration
 Diabetes insipidus
 Prolonged tourniquet time

29

What proteins are represented by the beta region on SPEP?

Transferrin (beta 1)

LDL (beta 1-beta 2 interface)

IgA and C3 (beta 2)

30

What are the primary and secondary cause of hypogammaglobulinemia on SPEP?

Primary:

XLA (Brutons agammaglobulinemia),
CVID (common variable immunodeficiency)
IgA (w/ IgG subclass: sinopulm/GI infections)
Hyper-IgM syndrome (CD40L--on T cells,CD40--on B cells, NEMO, AID)

Secondary:

Loss (nephrosis, burn, protein losing enteropathy)
Various forms of immunosuppresion
Chemotherapy for cancer
Irradiation for cancer
Immunosuppression for organ tx/AI Dz
Light chain disease