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 approximately 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 kappa/lambda 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 kappa/lambda 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.