Approximately 15% of the adult population have CKDThe current model of kidney care is referral pathways that are based on eGFR; this is consistent with the national guidelinesThe proposed model of kidney care utilises the CKD expertise within the catchment areaThe core issues are that1. Identification2. MonitoringThey are then seem people aged 18 years and  older included on the QOF CKD registers in the West Midlands. CKD is a major  risk factor for cardiovascular disease and mortality but is largely  asymptomatic until it reaches an advanced stage. It is estimated that there  could be approximately 83,000 people who are undiagnosed in the West Midlands.     Kidney function is measured by a simple blood test (eGFR). In CKD,  depending upon the underlying cause, eGFR can remain stable or decline  (progressive CKD). The majority of patients retain sufficient kidney function  to live out their natural life. However, those whose eGFR progressively  declines benefit from early specialist treatment to reduce the rate of decline  and hence the likelihood of requiring dialysis or a kidney transplant [1].     The traditional model of referral of  patients with CKD from primary to secondary care is based upon the staging of  CKD which is defined by the level of eGFR. Patients with CKD stage 3 are  generally cared for in primary care and referred to secondary care if they  reach stage 4 (defined by the patients’ eGFR falling below 30 ml/min/1.73m2)  as defined by NICE guideline CG 73. Patients with declining function but still  within stage 3 may not be recognised and so miss an opportunity to have earlier  specialist care [2]. This can lead to late presentation for RRT, which remains  an important cause of avoidable harm and premature death.    Once in secondary care, many patients  with stable CKD continue to attend outpatient clinics. They could be monitored  in primary care if there was a system of remote surveillance of their eGFR  trend to ensure it stays stable [2].      Optimal management of CKD relies upon: a) the patient having a  sufficient understanding of his/her condition and its treatment; b) the primary  care team monitoring the patient’s progress and modifying the treatment plan  accordingly; and c) the nephrology specialist in secondary care providing  advice and guidance at appropriate times and seeing patients in outpatient  clinics only when that adds value to the patient.     The HEFT renal and pathology departments operate an innovative  system for early detection and treatment of patients who are at the highest  risk of developing end stage renal disease (ESRD) [3]. In this system, the pathology  laboratory uses a database containing biochemical data from patients  (integrating results on blood samples taken in all settings) to generate  cumulative graphs of eGFR. The software facilitates the identification of those  patients with deteriorating kidney function, classifying them as low,  intermediate or high risk. For intermediate or high risk cases, the requesting  primary care clinician is sent a paper report of the eGFR graph with advice  about how to access nephrology advice. Once stable, patients can be discharged  from the outpatient kidney clinic and their kidney function followed remotely  via their eGFR graph.     Late presentation for RRT is a powerful and modifiable predictor  of poor outcome. Consequences of late referral include anaemia and bone  disease, low prevalence of permanent access, delayed referral for transplantation,  reduced choice of renal replacement modality, worse psychological adjustment to  ESRD, longer initial hospitalisation and increased mortality [5]. The rate of  patients presenting late to HEFT before starting dialysis, i.e. within 90 days,  has been the lowest in the UK since 2009.

Circulating monoclonal proteins (para-proteins) associated with B-cell disorders are very common. They occur in specific diseases, including Myeloma and AL-amyloidosis, and in pre-disease (monoclonal gammopathy of undetermined significance (MGUS)).These disorders can secrete both an intact immunoglobulin and a free immunoglobulin light chain, either in combination or separately. These monoclonal proteins can be quantified and are used as essential diagnostic tools in routine clinical practice, for the stratification and monitoring of risk of disease and, critically, the monitoring of disease activity. The Birmingham company, The Binding Site Ltd, is one of the leading companies for assays that measure monoclonal proteins. In particular, they developed the serum free light chain assay (Freelite) that has revolutionised diagnosis and monitoring for myeloma and other diseases that produce monoclonal proteins. However the assays to measure monoclonal proteins are imprecise in the era of stratified medicine. This imprecision has major implications for the care of patients.For example, for patients with myeloma treatment options have rapidly expanded in the past 15-years through the introduction of a number of new drugs including proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies. Through using these drugs in combination it has been possible to achieve deep responses in some patients including disappearance of the immunoglobulin monoclonal protein measured with current technologies.Following successful treatment, using genetic or immunophenotyping of bone marrow biopsies, it is possible to identify patients with less than 1 in 100000 malignant plasma cells. However the assays to monitor protein do not produce this level of sensitivity, and therefore the current standard of care for precise disease assessment is invasive for patients and prohibitively expensive for the healthcare economy. To address this requires the refinement of mass spectrometry, an extremely sensitive and specific technique for the quantification of proteins, for the characterisation and measurement of immunoglobulin proteins. The Binding Site Ltd is at the forefront of this field and have recently established a collaboration with the Mayo clinic, Rochester which will mean that all monoclonal proteins in a patient with myeloma or another B-cell disorder can be identified, classified and quantified simultaneously. This technology may have other potential benefits such as the ability to recognise early relapse and subclonal evolution during progression and to identify immunoglobulin proteins with particular properties such as the ability to damage kidneys, or nerves, or lead to amyloidosis. Early identification of immunoglobulin molecules capable of damaging kidney, nerves or producing amyloid would identify individuals at increased risk and guide treatment and monitoring strategies.A consistent and extremely sensitive method of measuring disease from blood sampling would be a tremendous advance from current technologies providing a consistent technique with greater levels of sensitivity and specificity and avoid the need for bone marrow biopsies.Senior clinicians at University Hospitals Birmingham Foundation Trust (UHBFT) have an international reputation in this area and feel that there is an outstanding opportunity through a joint collaborative project with the Binding Site Ltd to integrate mass spectrometry into the UHBFT clinical laboratory service and to develop the evidence base to transform the standard of care for diagnostics and monitoring for monoclonal diseases. The Binding Site will work with a major clinical research partner in Europe to complement the collaboration with the Mayo clinic and see UHBFT as the partner of choice.The aims of the collaboration will comprise1. Assay development and validationDevelopment and validation of the technique using sample collections from existing UK trials (Myeloma XI and Eulite) and prospectively from weekly samples from a large plasma cell disorder clinic at UHBFT.We will assess each step of the process including sample processing and preparation, optimisation of the mass spectrometry and analysis of mass spectrometric data.The cost, resource implications, turnaround times, sensitivity and specificity of the assay, and reproducibility and limitations of the assay, will be assessed relative to existing electrophoresis/immunofixation technologies. This will include health economic modelling and the development of standard operating procedures and frameworks for routine clinical practice.2. Assessment of sensitivity and specificity of mass spectrometry for minimal residual diseaseWe will compare mass spectrometry as a technology for assessing minimal residual disease compared with current technologies of electrophoresis/immunochemical techniques and flow cytometric analysisWe will use retrospectively collected samples from the Myeloma XI trial and from retrospective collections of amyloid patients from patients known to have had achieved a CR or MRD negative state.3. Development of an assay to identify monoclonal proteins that are nephrotoxic.Using bead technology we will separate immunoglobulin proteins capable of binding to Tamm Horsfall protein (that is associated with immunoglobulin and myeloma kidney damage) and other renal epitopes (HELP) and characterise them using mass spectrometric analysis.We have access to the Eulite study that will allow us to assess 40 patients with cast nephropathy and myeloma as a control population of patients with nephrotoxic light chains.4. Development of an assay to identify monoclonal proteins that are neurotoxic.Using bead technology we will separate immunoglobulin proteins capable of binding to myelin proteins and other recognised targets (that are associated with immunoglobulin related neuropathies) and characterise them using mass spectrometric analysis.We have a strong collaboration with Prof Yusuf Rajabally Professor of Neurology at UHBFT who is an international expert in this area.5. Characterisation of monoclonal proteins that are capable of forming amyloid.Using retrospectively stored samples from amyloid patients we will characterise light chains from patients from amyloid and compare these using mass spectrometry to light chains from patient with plasma cell disorders who do not have amyloid. This will help characterise subtle differences in light chain modifications such as glycosylation and protein structure in greater detail than existing techniquesClinical and laboratory Service University Hospitals Birmingham NHS Foundation TrustThe myeloma service at University Hospitals Birmingham Foundation Trust (UHBFT) is now based at two sites. These are led by Drs Guy Pratt and Mark Cook at QEHB and Dr. Bhuvan Kishore at the Heart of England NHS Foundation Trust (HEFT). As these two former Trusts have recently merged this has established the largest clinical myeloma service in the UK. The renal unit at UHBFT is a large academic unit that has an international reputation in plasma cell related renal problems led by Professor Paul Cockwell and Dr Jenny Pinney. Academic ambition is at the heart of clinical practice at the Birmingham Centre. The joint Haematology units have a strong tradition of support for clinical trials within myeloma. HEFT was the top recruiter to Myeloma XI and UHBFT is currently the top recruiting centre to MUK 7. We have extensive experience in leading on clinical trials as principal investigators, co-investigators (TEAMM, R2W, MUK14, MUK9) and chief investigators (LenaRIC, Eulite, PICCLE, MUK15). The West Midlands is one of the largest UK centres for cancer treatment, with an ethnically and socio-economically diverse regional population of 5.5 million people. We have a strong regional myeloma network with regular regional myeloma leads meeting involving Dr Basu (New Cross, Wolverhampton), Dr Shaffiq (Worcester) and Dr Wandroo (City and Sandwell) to develop regional initiatives. The Birmingham Centre for Clinical Haematology based at UHBFT is one of the leading academic haematology centres in the UK. It has recently received a £3 million grant to expand the unit allowing for a substantial increase in our research and trial capacity.The Binding Site LtdThe Binding Site has been at the forefront of the development of immunological assays in multiple myeloma and other B-cell disorders. The company’s Freelite® assay is the only serum free-light-chain assay approved by the U.S. Food and Drug Administration to help diagnose and monitor patients with B-cell disorders and is now established globally as the standard of care in diagnosis, monitoring and prognosis of the disease. The company also invented and developed the Hevylite™ assay which has added significant value in understanding intact immunoglobulin multiple myeloma patient responses. Together, these assays have been the subject of some 650 peer-reviewed journal articles. The output of this collaboration will build on The Binding Site’s core expertise in understanding methods to identify and measure monoclonal immunoglobulins and will revolutionize the approach in the clinical laboratory.