What further monitoring is needed for a patient with decreased kappa light chains (from 2.26 to 2.13) and normal protein electrophoresis, in the context of normal beta 2 microglobulin (2.01) and elevated ferritin (Fe) levels (165)?

From the Guidelines

Regular monitoring of kappa light chains, serum protein electrophoresis, and beta-2 microglobulin is recommended every 3-6 months, with a focus on the separate issue of elevated iron levels, which should be evaluated with additional tests including total iron binding capacity, ferritin, and transferrin saturation to rule out hemochromatosis or other iron overload conditions, as suggested by the 2022 EASL clinical practice guidelines on haemochromatosis 1. The slight decrease in kappa light chains from 2.26 to 2.13 is reassuring, and the normal protein electrophoresis without monoclonal immunoglobulins suggests no evidence of a plasma cell disorder. The beta-2 microglobulin level of 2.01 is within normal range, indicating low risk. Some key points to consider in the monitoring of iron levels include:

• The target for iron depletion during induction is a serum ferritin of 50 lg/L, but not lower to avoid iron deficiency, as recommended by the 2022 EASL guidelines 1
• Serum ferritin should be monitored every 6 months to adapt the treatment schedule and ensure that ferritin remains within the target range, as suggested by the 2022 EASL guidelines 1
• Unexpected changes in serum ferritin or transferrin saturation levels should always be investigated, as significant fluctuations are not a feature of haemochromatosis, as noted in the 2022 EASL guidelines 1
• It is advisable to periodically check plasma folate and plasma cobalamin, especially in patients who require numerous venesections; if necessary, vitamin supplements should be administered, as recommended by the 2022 EASL guidelines 1 During follow-up visits, a complete blood count, comprehensive metabolic panel, and assessment for symptoms like bone pain, fatigue, or recurrent infections should be performed. This monitoring approach balances vigilance for potential progression of any underlying plasma cell disorder while addressing the separate issue of elevated iron levels, and is in line with the recommendations of the 2011 American Association for the Study of Liver Diseases practice guideline on the diagnosis and management of hemochromatosis 1.

From the Research

Monitoring Requirements

• The patient's kappa light chains have decreased from 2.26 to 2.13, and protein electrophoresis is normal with no monoclonal immunoglobulins 2.
• Beta 2 microglobulin levels are 2.01, which is a relevant factor in monitoring multiple myeloma and other plasma cell dyscrasias 3, 4.
• The serum free light chain test is more sensitive than urine electrophoresis for monitoring multiple myeloma, especially in patients with low monoclonal protein levels 5.
• A higher serum free light chain difference or β2-microglobulin levels are risk factors for thromboembolic events in patients with AL amyloidosis 4.

Further Monitoring

• Regular monitoring of serum free light chains and beta 2 microglobulin levels is necessary to assess the patient's condition and risk of thromboembolic events 5, 4.
• Protein electrophoresis should be repeated periodically to check for the presence of monoclonal immunoglobulins 2.
• The patient's iron level (Fe) is 165, but there is no direct evidence in the provided studies to suggest that this is relevant to the monitoring of multiple myeloma or plasma cell dyscrasias.

Relevant Studies

• Studies have shown that serum free light chain measurements are useful in monitoring multiple myeloma and other plasma cell dyscrasias 5, 4.
• Beta 2 microglobulin levels are also an important factor in monitoring these conditions 3, 4.