A N N A L S O F C L IN IC A L A N D LA BOR ATO RY S C IE N C E , Vol. 20, N o.

3
C o p y rig h t 1990, I n s titu te for C linical S c ien c e , Inc.

P2Microglobulin: Its Significance

and Clinical Usefulness
MARC BETHEA , M .D .
and DO NA LD T. FORM AN, Ph.D .

Division o f Clinical Chemistry,

North Carolina Memorial Hospital,
University o f North Carolina,
Chapel Hill, NC 27599

ABSTRACT

P2-Microglobulin (P2M), an interesting and underutilized m etabolite,

can be used in assessing renal function, particularly in kidney-transplant
recipients and in patients suspected of having renal tubulointerstitial dis
ease. It also can serve as a nonspecific b u t relatively sensitive m arker of
various neoplastic, inflammatory, and infectious conditions. Early hopes
that it would be a useful serum test for malignancy have not been fulfilled,
b u t it does have prognostic value for patients with lymphoproliferative
disease, particularly m ultiple myeloma. More recent reports have sug
gested a role for (J2M as a prognostic m arker in hum an im m unodeficiency
virus (HIV) infection.

Introduction proliferative disease and its prognostic

Since its isolation in 1964 from the
u rine of patients w ith W ilsons disease
and workers exposed to cadm ium , 3 2-
M icroglobulin (|32M) has elicited interest
both as an indicator of renal function and
as a relatively sensitive though nonspeci
fic m a rk e r o f c e rta in m a lig n a n c ie s ,
autoim m une diseases, and viral infec
tions, m ost recently acquired im m uno
deficiency syndrom e (AIDS). An over
view is provided of the current status of
f$2M assay w ith particular em phasis on
its role in the m anagem ent of lympho-
* Send reprint requests to Donald T. Forman,
Ph.D ., Division of Clinical Chemistry, 1067 Patient
Support Tower, North Carolina Memorial Hospital,
University of North Carolina, Chapel Hill, NC 27599.
163
0091-7370/90/0600-0163 $00.90 Institute for Clinical Science, Inc.
value in HIV infection.
P2-Microglobulin has been identified
as th e lig h t c h a in c o m m o n to th e
HLA-A, -B, and -C m ajor histocom pati
bility complex antigens, and, as such, is
expressed on the surface of virtually all
n orm al n u c le a te d cells as w ell as by
m any tum or cell lines. A low concentra
tion of free p2M, about 0.9 to 2.5 mg per
L, is found in the serum of healthy sub
jec ts, a p p a re n tly re fle c tin g its sh e d
ding from the cell m em brane as a con
sequence of the turnover of H LA .26 The
surfaces of lymphocytes and monocytes
are particularly rich in (32M, and lym
phocytic synthesis and expression are
further augm ented by stimulation with
m itogens or w ith interferons.2 Although
th e fu n ctio n of surface P2M rem ain s
164 BETHEA AND FORMAN
o b sc u re , in c re a se d c o n c e n tra tio n s of
(32M in serum have b e e n consistently
observed in conditions characterized by
lym phocyte activation and (or) prolifera
tion. (32-M icroglobulin m ay th ere fo re
serve as a useful nonspecific marker, in
the absence of renal insufficiency, of sys
tem ic lymphocytic activation. In table I
a re d e s c rib e d various im m unological
p ro p e rtie s of |32M. In th ese settings,
high serum (32M values can be thought of
as a re s u lt o f in creased sy n th esis
w hether owing to increased expression,
increased HLA turnover, cell prolifera
tion, cell lysis, or some combination of
these - and not of decreased renal clear
ance.14
Significance of in Renal D isorders
The unique features of the renal han
dling of 02M have prom pted investiga
tion into its role in evaluation of renal
function, p articu larly in kidney tra n s
p la n t re c ip ie n ts an d in p a tie n ts su s
p ected of having tubulointerstitial dis
e a se .24 By v irtu e of its low m olecular
mass (11800 Da), (32M is easily filtered
through the glom erular basem ent m em
brane. Its rapid elim ination is accom
plished almost exclusively by glomerular
TABLE I
Immunologic Characterization of
Beta-2-MicroglobuIin (8 2 M)
32M is non-covalently associated with
histocompatibility antigens.
B2m may control the expression of antigens on the
cell surface and possibly their biosynthesis.
B2M has an amino acid homology and structural
similarity to the CH3 region of IgG.
S2M is antigenically distinct from IgG.
82M does not bind to antibody-coated protein
A-bearing Staphylococcus aureus.
$2M appears to inhibit phytohemagglutinin (PHA)
induced lymphocyte transformation.
Mitogen-induced lymphocyte stimulation in vitro
results in marked increase of 02M production.
filtration. O f the filtered 32M, 99.9 p er
cent is then taken up by endocytosis into
proxim al tu b u lar cells and catabolized
into its constituent amino acids. Serum
(32M determ inations have been used to
follow changes in glom erular filtration
rate (GFR); urinary excretion above the
norm al maximum of approxim ately 370
jxg p e r 24 h o u rs is tak e n to in d ic a te
tubular dysfunction.
Both of these variables have been uti
lized in the m anagem ent of renal-trans-
plant patients, a setting in which rapid
changes in G FR may be se en .13 In the
presence of acute rejection, serum (32M
c o n c e n tra tio n s ty p ic a lly b e c o m e in
creased days b efore serum c re a tin in e
in c re a s e s ; f u rth e rm o re , s e ru m p 2M
values are in dependent of body mass or
sex. A stable serum (32M in the face of
postsurgical oliguria m ay h e lp d istin
guish acute renal failure from rejection,
and its increased urinary excretion may
signify cyclosporin A toxicity.22 The use
of 02M determ inations m ust take into
account th e ir nonspecificity; how ever,
because an increased serum (32M in this
setting may be seen in system ic cyto
m egalovirus infection, it could prom pt
inappropriate high-dose steroid therapy
if used as the sole criterion of rejection.3
P2-Microglobulin has also been d e te r
m ined in urine as an early indicator of
am inoglycoside or lithium toxicity; to
screen for heavy m etal (cadmium, m er
cury) poisoning in appropriate popula
tions; to help differentiate infections of
the upper urinary tract from those of the
lower urinary tract; and as an adjunct in
th e diagnosis of acute tubular necrosis.24
Significance of (i2M in N eoplasia
An association betw een increased (32M
in serum and the presence of malignancy
was n o te d by sev eral o b se rv e rs soon
a fte r th e p ro te in was c h a ra c te riz e d ,
prom pting a flurry of reports concerning
its possible use as a tum or m arker (fig
 CLINICAL USEFULNESS O F pr MICROGLOBULIN 165

/3-CELL
NEOPLASIA

Plasms Cell i
83
Tumors 8
Non-Hodgkins
9 I
Lymphoma
CHR Lymphocytic
| 5 j j
Leukemia
Multiple
O i
Myeloma
M
Lymphosarcoma 27 F i g u r e 1. Concentra
Reticulum Cell tion of serum P2M in var
11 io u s B -c e ll n e o p la sia s ,
Sarcoma
solid m alignancies, m is
OTHER cellaneous malignancies,
and various benign infec
Solid Tumors* 77 ? ? tious disorders. Gray stip
?S* pled area on figure repre
Monocytic sents a number of subjects
5
Leukemia w ith in th e r e fe r e n c e
Hodgkins interval (0.9 to 3.0 mg per
13
Disease 1) in the population stud
Infectious 15 M IM ied .14
Mononucleosis
Viral ,
Hepatitis m

Chronic Active
7 1 M
Hepatitis
Primary Biliary
Cirrhosis iisS
1 1 1 1 1 1 1 \ I I 1 1 1 " 1 "
0 <3 4 5 6 7 8 9 10 11 12 13 14 15

Serum /32-rnicroglobulin ( m g / L )
^includes head, neck, hepatoma, colon, pancreas, stomach, lung, breast, and cervix

u re I ) .14,25 p 2-M icroglobulin has since mg per L had a dramatically longer sur
fallen p rey to th e difficulties en c o u n vival tim e (m ed ian , 52 m onths) th an
tered with o ther serum tests for cancer: th o s e w ith v a lu e s > s ix m g p e r L
disappearance of predictive pow er w hen (m e d ia n , 26 m o n th s ). S u b s e q u e n t
applied to unselected populations, unac- reports, w ith one exception,28 confirm
ceptably low specificity, and the like.23 It the predictive pow er of serum (32M assay
has retained some favor as an adjunct in an d n o te sig n ifican t c o rre la tio n w ith
the staging of m ultiple m yeloma (MM) stage and tum or cell m ass.1 Garewal et
and to a lesser degree in B-cell chronic al.16 found that, in some patients, serum
lym phocytic leukem ia (B-CLL), how (32M appeared to correlate b e tte r w ith
ever, and may be of use in selected cases observed response to treatm ent than did
in other lym phoproliferative disorders.19 changes in the concentration of the M-
Bataille e t a l.4 c o rre la ted p re -tre a t- component. Serum (32M values m ust be
m e n t serum (32M values for 115 MM in te rp re te d w ith caution in MM; how
patients w ith o th er prognostic features ever, although a statistically significant
and with subsequent course. They found difference can be dem onstrated betw een
serum (32M to have powerful predictive (32M values in p a tie n ts w ith b e n ig n
value independent of the effect of dim in monoclonal gamm opathies and patients
is h e d c r e a ti n i n e c le a r a n c e . T h o se w ith stage I m yelom a, th e re is a not
patients with pre-treatm ent values <six inconsiderable overlap betw een the two
166 BETHEA AND FORMAN
g roups.19 M ore im portantly, th ere is a
subset of patients with MM (eight of 90
in a 1987 prospective study5) who never
show an increase in serum (32M.
T he v a lu e o f d e te rm in in g 3 2M in
patients w ith B-CLL is less well-estab
lished. Melillo e t al19 showed a consis
tent increase in pre-treatm ent values for
a group of 34 patients, as well as signifi
cant correlation with clinical stage (Stage
I vs III or IV, Stage II vs III or IV; P <
0 .0 5 ) a n d a s ig n if ic a n t (P < 0 .0 1 )
decrease in values for patients respon
sive to therapy. However, the study con
firm ed earlier reports of a wide overlap
b e tw e e n p r e - t r e a tm e n t v a lu e s a n d
values in responders and also failed to
show a retu rn to normal concentrations
in any patient. The latter likely reflects a
tru e phenom enon, because com plete
eradication o f th e neoplastic clone in
C LL is rare. Ellegaard e t al11 concluded
th a t re p e a te d 2M d eterm in atio n s in
serum may be of value in estim ating the
residual tum or mass after therapy, a con
clusion shared by other investigators.19
S ev eral stu d ie s have a tte m p te d to
define a role for (32M assay in the m an
a g em en t of non-H o d g k in s lym phom a
(NHL) or in H odgkins disease (HD).
A ltho ugh sta tistic a l co rre la tio n s w ith
stage at diagnosis and histological grade
have been shown, the wide dispersion of
values lim its th e usefulness of serum
(32M as a m arker of disease activity.19 In
a d d itio n , H D p a tie n ts in fre q u e n tly
exhibit a significantly increased serum
(32M unless they have w idespread dis
ease. M easurem ents of (32M in cerebro
spinal flu id (CSF) m ay have value in
detecting th e presence of lymphom a or
leukem ia in the central nervous system,
a lth o u g h r e p e a t te sts for re c u rre n c e
m u s t ta k e in to a c c o u n t n o n s p e c ific
increases in CSF-fS2M owing to intrathe
cal chem otherapy.21
S ig n ifica n tly in c re a s e d v alu es for
s e ru m a re n o t lim ite d to ly m p h o id
malignancies and have been observed in
som e solid tum ors as w ell (figure 1).
The clinical utility of this observation is
questionable, however. Lotzniker et al18
published a surprising result based on a
study of 186 carcinoma patients. Those
w ith stage IV disease had significantly
low er serum (32M values than those in
stages II or III (P < 0.01). Im m unohisto-
logical studies w ith use of antibodies to
surface (32M have shown a tendency for
decreased expression in m ore poorly dif
ferentiated carcinomas.2429 Lotzniker et
a l18 s p e c u la te d th a t seru m |32M may
serve as an interesting m arker of differ
entiation rather than a tum or m arker per
se; decreased serum (32M m ight directly
reflect less tum or cell HLA turnover or
m ay in d ic a te an im p a ire d im m u n e
re s p o n s e d u e to a lte re d re c o g n itio n
sites.
Significance of Serum p2M in Chronic
Inflammatory Conditions and in AIDS
Serum |32M values are in creased in
some chronic inflamm atory or possibly
autoim m une conditions, including sys
tem ic lupus erythem atosus, rheum atoid
a r t h r it is , S jo g re n s s y n d ro m e , a n d
C r o h n s d is e a s e , a m o n g o t h e r s . 14
Reviews of the utility of (32M as a m oni
tor of disease activity have been mixed.
Dixon e t al10 pointed out the difficulty of
a s se s s in g th e c o n tr ib u tio n o f re n a l
im p a irm en t to an in creased value for
(32M in serum , particularly in patients
who m ay have subclinical glom erular
and tu b u lar dysfunction resulting from
chronic non-steroidal anti-inflam m atory
dru g use. p 2-M icroglobulin has b een
m easured in synovial fluid and saliva in
rheum atoid arthritis and Sjogrens syn
drom e, respectively, and suggested as
indices of lymphocyte turnover.
A 32M response has been shown in
certain viral infections, including infec
tious m ononucleosis, cytom egalovirus,
 CLINICAL USEFULNESS O F P,-MICROGLOBULIN
non-A non-B hepatitis,8 and A ID S.15 The
n o n sp e c ific ity a n d v a ria b ility of th e
response ren d er it of little value for diag
nostic purposes, although a high value in
an im m u n o su p p re sse d p a tie n t m ight
prom pt the clinician to consider the pos
sibility of opportunistic viral infection.8
(32-Microglobulin may also play a role in
ev a lu a tin g p rogn osis and m o n ito rin g
tr e a tm e n t in H IV -in fe c te d p a tie n ts .
Bhalla et al6 reported above-normal con
centrations in 29 of 31 AIDS patients as
well as five of 11 asymptomatic homosex
ual m en. Zoila-Pazner e t al30 prospec-
tively studied 40 asym ptom atic hom o
sexual m en from New York City, whose
cases w ere followed for two years. Six of
th e seven subjects w ith in itial serum
value > 2 .5 mg p er L developed AIDS,
whereas none of the rem aining subjects
p ro g re s s e d to A ID S d u rin g th e tw o
years. Recent reports at the Fourth and
F ifth In te rn a tio n a l C onference(s) on
AIDS (Stockholm, June 1988 and M on
treal, June 1989) continue to substantiate
that serum (32M is a useful surrogate test
for predicting the developm ent of AIDS.
One paper, based on a prospective study
of 215 H IV -antibody-positive subjects
whose cases w ere followed for a m edian
period of 30 m onths, suggested a m ulti
variate m odel for predicting AIDS by
TABLE II
Use of Serum Beta-2-Microglobulin, Urinary Neopterin
and T-Cell Subsets in Predicting the Progression
of HIV Disease in Hemophiliacs
Relative Risk of
Developing CDC Group IV
Test Result Disease in Four Years
CD-4 < 200 28 (p = 0.07)
82M > 3 . 0 mg/L 10 (p = 0.02)
Neopterin > 15 nmol/L 6 (p = 0.11)
(3.8 ng/L)
Cuthbert, R.J.G.: Combination of beta-2-microglobuin,
neopterin and T-cell subsets is useful in
predicting the progression of HIV disease in
hemophiliacs. Poster T.B.P. 74, Fifth International
Conference on AIDS, Montreal, Canada, June 6, 1989.
167
use of serum p2M determ inations, C 0 4 -
positive lym phocyte counts, and m ea
surem ents of anti-p24 and p24 antigen.20
In table II is shown the relative risk of
d e v e lo p in g C D C G ro u p IV d ise a se .
A nother p resen tatio n suggested th at a
decrease or normalization of serum (32M
during th e first eight to 12 weeks of aza-
thioprine (AZT) therapy was predictive
of a stable clinical status for 14 to 18
m onths.17 An additional report showed a
strongly positive correlation b e tw e en
clinical severity of A ID S-dem entia com
plex and p2M concentrations in the cere
brospinal flu id .7
M easurem ent of (J2M
T h e re are several reliable m ethods
quantifying pi2M, including laser nephe-
lo m e tr y ,9 ra d io im m u n o a s s a y ,27 a n d
enzym e immunoassay.12 The last two are
the m ore sensitive and widely used tech
niques. These two m ethods allow detec
tion of trace am ounts of P2M in normal
serum and urine and effectively distin
guish norm al from high concentrations.
32-M icroglobulin is stable in serum ,
and samples can be stored at 20C for
as long as a year. U rinary assays are
problem atic, how ever, because (32M is
rapidly degraded at pH s < 6.0. Although
some investigators simply add alkali to
the specim en, Schardijn24 recom m ends
giving the subject four g of sodium bicar
bonate on the evening before collection
and an additional divided dose of four g
d u rin g th e 24 h o u r p eriod to obviate
degradation w ithin the bladder.
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2. Az o c a r , J., E s s e x , M ., W a t s o n , A ., G a z it , E .,
A n d e r s o n , D ., and Y u n is , E .: Changes in the
expression of HLA and p2microglbulin by cul
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293, 1982.
168 BETHEA AND FORMAN
3. Backman, L., Rin g den , D ., Bjrkhen , I., and
LlNDBACK, B.: Increased serum p2-microglobu-
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Beta-2-microglobulin for differentiation between
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W il s o n , D ., and Y o u n g , D.: {J2-Microglobulin
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28. van D o b b e n b u r g h , O ., R o d e n h u is , S., O u k -
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29. W a l t o n , G ., M c C u e , P., and G r a h a m , S .:
B eta-2 -m icro g lo b u lin s as a d ifferen tia tio n
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30. Z o l l a -P a z n e r , S ., W il l ia m , D ., E l S a d r , W .,
M a r m o r , M ., and S t a h l , R .: Q uantitation of
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