Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • any new paraprotein with features of:
    • acute worsening renal impairment,
    • hyperviscosity (headaches, visual changes, epistaxis)
    • symptomatic hypercalcaemia (confusion, electrocardiogram (ECG) changes)
    • threatened spinal cord compression (back pain, urinary or bowel incontinence, lower limb sensory changes).

Please contact the duty haematologist via switchboard so the referral may be expedited, and the patient reviewed as soon as possible.

For clinical advice, please telephone the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Exclusions

  • raised immunoglobulin levels without:
    • a monoclonal paraprotein band on serum electrophoresis and/or
    • raised serum kappa OR lambda free light chains with an abnormal ratio and/or
    • presence of urinary Bence Jones proteins

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • any paraprotein, abnormal kappa or lambda light chain results with:
    • recent onset unexplained anaemia
    • recent unexplained significant renal impairment
    • asymptomatic mild hypercalcaemia
    • lytic bone lesions or pathological fracture, not at risk of cord compromise
    • unexplained cardiac failure
    • significant urinary proteinuria
  • significant elevation of serum kappa or lambda free light chains (>1000)

Category 2 (appointment clinically indicated within 90 days)

  • nil

Category 3 (appointment clinically indicated within 365 days)

  • any new paraprotein, abnormal kappa or lambda light chain results without any features of symptomatic myeloma, lymphoproliferative disorder or amyloidosis. Usually seen within 3 to 6 months.

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • medication history
  • current medication list
  • physical examination of the skin, all lymph node groups, abdomen, neurological and cardiorespiratory examination
  • blood results:
    • complete blood examination (CBE)
    • blood film examination
    • liver function tests (LFTs)
    • electrolytes, urea, creatinine (EUC)
    • estimated glomerular filtration rate (eGFR)
    • lactate dehydrogenase (LDH)
    • calcium
    • serum electrophoresis (EPG) and immunofixation to confirm underlying monoclonal protein
    • serum free light chains
    • Beta-2-microglobulin
    • Urine Bence Jones protein
  • CT skeletal survey or any other prior imaging. An IgM paraprotein is more commonly associated with a lymphoproliferative disorder. Hence please organise CT neck, chest, abdomen, pelvis and refer to the lymphadenopathy CPC and lymphocytosis CPC.

Clinical management advice

Monoclonal proteins, detected on serum protein electrophoresis, may be associated with plasma cell dyscrasias such as monoclonal gammopathy of uncertain significance (MGUS), multiple myeloma, amyloidosis, or lymphoproliferative disorders such as chronic lymphocytic leukaemia (CLL), Waldenstroms macroglobulinaemia.

Monoclonal gammopathy of undetermined significance (MGUS) is a diagnosis of exclusion: 3% of over-70s have paraproteins which are frequently found incidentally and not associated with symptoms or physical findings. The overall risk of MGUS progression to myeloma is around 1% per year – this remains constant over time.

Occasionally, in MGUS or multiple myeloma, there also may be abnormal clonal light chain production resulting in a clonal proliferation of either kappa or lambda light chains with an abnormal involved light chain/uninvolved light chain ratio. In addition, renal impairment or inflammation/infection can also cause an increase in the involved light chain/uninvolved light chain ratio. This ratio is also higher in older people. In the recently published ISTOPMM study (n=41,882), the reference intervals for serum free kappa or lambda light chain using the Freelite assay was performed. The study suggested a revised reference range of free light chain ratio in healthy people age ≥70 from 0.46 to 2.59. In individuals with moderate-severe renal impairment, the radio can range from 0.54 to 3.30.

Bone scans are usually negative for the lytic lesions seen in myeloma. A computed tomography (CT) skeletal survey is recommended to screen for myeloma related lytic lesions.

Immunoglobulin M (IgM) monoclonal protein is exceedingly rare in myeloma and is more commonly seen in low grade lymphomas.

Clinical resources

Consumer resources

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

  • full name, including aliases
  • date of birth
  • residential and postal address
  • telephone contact number/s – home, mobile and alternative
  • Medicare number, where eligible
  • name of the parent or caregiver, if appropriate
  • preferred language and interpreter requirements
  • identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

  • impact on employment
  • impact on education
  • impact on home
  • impact on activities of daily living
  • impact on ability to care for others
  • impact on personal frailty or safety
  • identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery, where surgery is a likely intervention.
  • Choice to be treated as a public or private patient.
  • Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
  • A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.