CSF free light chain identification of demyelinating disease: comparison with oligoclonal banding and other CSF indexes

Background: Cerebrospinal fluid (CSF) used in immunoglobulin gamma (IgG) index testing and oligoclonal bands (OCBs) are common laboratory tests used in the diagnosis of multiple sclerosis. The measurement of CSF free light chains (FLC) could pose as an alternative to the laborintensive isoelectric-focusing (IEF) gels used for OCBs. Methods: A total of 325 residual paired CSF and serum specimens were obtained after physician-ordered OCB IEF testing. CSF kappa (cKFLC) and lambda FLC (cLFLC), albumin and total IgG were measured. Calculations were performed based on combinations of analytes: CSF sum of kappa and lambda ([cKFLC + cLFLC]), kappa-index (K-index) ([cKFLC/sKFLC]/[CSF albumin/serum albumin]), kappa intrathecal fraction (KFLCIF) {([cKFLC/sKFLC][ 0.9358 x CSF albumin/serum albumin](boolean AND)[0.6687 x sKFLC]/cKFLC)} and IgG-index ([CSF IgG/CSF albumin]/[serum IgG/serum albumin]). Results: Patients were categorized as: demyelination (n = 67), autoimmunity (n = 53), non-inflammatory (n = 50), inflammation (n = 38), degeneration (n = 28), peripheral neuropathy (n = 24), infection (n = 13), cancer (n = 11), neuromyelitis optica (n = 10) and others (n = 31). cKFLC measurement used alone at a cutoff of 0.0611 mg/dL showed > 90% agreement to OCBs, similar or better performance than all other calculations, reducing the number of analytes and variables. When cases of demyelinating disease were reviewed, cKFLC measurements showed 86% clinical sensitivity/77% specificity. Conclusions: cKFLC alone demonstrates comparable performance to OCBs along with increased sensitivity for demyelinating diseases. Replacing OCB with cKFLC would alleviate the need for serum and CSF IgG and albumin and calculated conversions. cKFLC can overcome challenges associated with performance, interpretation, and cost of traditional OCBs, reducing costs and maintaining sensitivity and specificity supporting MS diagnosis.