Quantitative Serum Free Light Chain Assay – Analytical Issues

Serum free light chain (FLC) assay is an important advance in the diagnosis and monitoring of monoclonal light chain diseases and a complementary test to serum protein electrophoresis and immunofixation. Immunoturbidimetric and immunonephelometric assays for serum FLC are available on routine chemistry analysers and can detect FLC down to ~1 mg/L. These assays use polyclonal anti-human FLC antisera and require acceptable imprecision, specificity, accuracy, and reproducibility between reagent batches to prevent under- or over-estimation of FLC concentration.Assay imprecision determined between reagent lots has a variation of 8–45% for FLC concentrations and 17–32% for the calculated κ/λ FLC ratio. Dilution studies indicate some over-recovery of FLC, which may depend upon the dilution matrix. However, greater discrepancies are underestimation from nonlinear reactions and overestimation possibly from interferences or multi-reactivity to polymeric FLC. Nonlinear monoclonal FLC give concentrations which are 2- to 6-fold increased at higher sample dilution and FLC measured on different platforms may not give the same results.Laboratory staff and clinicians should be aware of the analytical limitations of the FLC assay. Assay imprecision, especially with different lots of FLC reagent, may have a significant effect on changes in the FLC concentration and κ/λ FLC ratio. Sample dilution anomalies have the potential to confound result interpretation for patients with monoclonal light chain disease. These issues, if not adequately appreciated, have the potential to mislead clinical diagnosis and assessment of response to therapy.Serum free light chain (FLC) assay came into routine clinical laboratories following the publication in 2001 describing the presence of monoclonal FLC in 19/28 non-secretory myeloma (NSMM) patients at diagnosis.¹ Use of the assay has grown globally since that time and other retrospective clinical studies have shown the clinical utility of FLC in serum as a complementary test to serum protein electrophoresis (SPEP) for the diagnosis and monitoring of monoclonal light chain diseases.Monoclonal immunoglobulin free light chains are important tumour markers often present in serum and urine of patients with monoclonal gammopathies. Serum kappa (κ) and lambda (λ) FLC assays measure total polyclonal and monoclonal FLC in serum and the calculated κ/λ FLC ratio is a surrogate measure of clonality. Retrospective studies have shown serum FLC is clinically indicated for diagnosis and prognosis in plasma cell proliferative disorders, including primary amyloidosis (AL), NSMM, light chain multiple myeloma (LCMM), light chain deposition disease (LCDD) and solitary plasmacytoma; in documenting stringent complete response in multiple myeloma (MM); and for routine serial measurement to assess response in the oligosecretory diseases, NSMM, AL and LCDD.² Serial measurements may also be indicated in MM when serum M-protein is <10 g/L or urinary Bence Jones protein (BJP) excretion is <200 mg/24h.³ However, there is currently no data to support its use in the monitoring of MM where disease is measurable by other methods such as SPEP. (Refer also to the review on FLC by J Katzmann in this issue).