IMMUNOCHEMICAL TECHNIQUES Immunoassay (including radial immunodiffusion, Laurell socket immuno electrophoresis, ELISA, and radioimmunoassay among others)

is assuming great importance. Immunoassay techniques quantitate individual proteins rather than protein groups and in general produce reliable results with excellent sensitivity and specificity. Immunoelectrophoresis can be used to separate some of the individual globulin molecules into structural components or into subclasses.

It can also detect abnormal proteins that can either differ structurally from normal proteins or that are produced with different proportions of structural components. Chemical methods such as the Biuret reaction, Kjeldahl technique and even the BromoCresol Green technique for the determination of albumin are useful mainly to detect hyperglobulinemia and hypoalbuminemia.

However, they are poorly sensitive for hypoglobulinemia and not particularly sensitive even for hyperglobinemia, due to the wide population reference range, the differences among various chemical methods and the unpredictable influence of all the various globulin molecules on the total result.

 Electrophoresis is also used as a screening test, and in addition to partial separation of the globulins can suggest certain diagnosis or diagnostic possibilities by means of certain patterns of change in the electrophoretic fractions.

Immunoassay permits accurate quantitation of various individual serum proteins and thus can either provide a diagnosis (e.g. 1-antitrypsin deficiency) or suggest diagnostic possibilities (e.g. hypogammaglobulinemia or increased transferrin). On electrophoresis of serum using cellulose acetate strip, 5main protein fragments are obtained.

These are albumin and the 1-, 2-, -, -globulins. Each of these fractions includes many proteins.

A special instrument (densitometer) translates the quantity of protein or density of the bands into a linear pattern which is a rough visual approximation of the amount of substance present.
Albumin is the most abundant and the most obvious band. The 1- globulin band consists almost entirely of 1antitrypsin;

The 2-globulin band consists mainly of 2macroglobulin,cerulopasmin and the haptoglobin.

The -globulin can separate into two bands: 1 and 2. 1 consists mainly of transferrin, and 2 consists of the complement component 3 (c3), -lipoprotein.
The -globulins are mainly immunoglobulins. Some immunoglobulins are also found in the 2 and regions. If however, plasma is used instead of serum, fibrinogen forms a 6th band between the - and -globulins.

PRINCIPAL FUNCTIONS OF PLASMA PROTEINS

1.Transport: performed mainly by albumin and specific binding proteins. Albumin binds and transports: Free fatty acids and esterified fatty acids (FFA and NEFA). Excretory products such as bilirubin, metals such as calcium. Many drug such as salicylates and some penicillin as well as other toxic ingested substances.

Specific binding proteins transport: .

Hormones such as thyroxine and cortisol

Metals such as copper and iron, and other substances such as haemoglobin and cobalamin. The lipoproteins act as major carriers of the lipids of the plasma. 2.Maintenance of colloid (oncotic) osmotic pressure The plasma proteins particularly albumin are required for the maintenance of colloid/ oncotic osmotic pressure.

Oncotic pressure is the osmotic pressure due to the presence of proteins and is an important factor in the distribution of extracellular fluid (ECF) between the intravascular and extravascular compartments. In hypoalbuminemia states, the decreased plasma oncotic pressure disturbs the equilibrium between the plasma and interstitial fluid so that there is a decrease in the movement of interstitial fluid back into the blood at the venular end of the capillaries. The accumulation of interstitial fluid is seen clinically as oedema.

Serum proteins, particularly albumin is very active in maintaining the serum oncotic pressure (i.e. the distribution of water between the intra- and extravascular compartments).

3.Inflammatory Response and Control of Infection

The main defense proteins are the immunoglobulins and the complement proteins. Also the complement together with a group of proteins referred to as acute-phase reactants; are involved in the inflammatory response. The acute-phase reactants include C-reactive proteins, 1antitrypsin and haptoglobins,alpha 1 acid glycoprotein,fibrinogen,ceruloplasmin.

4.Buffering Capacity This is a minor role of the plasma proteins. (It is however, a very important function of haemoglobin), thus maintenance of acid-base balance. 5.Enzymatic Activity Many of these proteins circulate in the blood plasma but only a few circulating enzymes are functional; other enzymes are liberated for instance, as a result of tissue damage. 6.Clotting and Fibrinolysis Plasma proteins such as fibrinogens are involved in clotting of blood to prevent blood losing. Plasminogen and plasmin are important in fibrinolysis.

PROPERTIES AND FUNCTIONS OF THE INDIVIDUAL PLASMA PROTEINS

ALBUMIN Albumin is synthesized in the parenchymal cells of the liver. It has a molecular weight of about 65,000 and a sedimentation coefficient of 4s; and a normal plasma biological half-life of 20 days. It is the most abundant of plasma total protein with a normal level of about 36-47g/l or 30-45g/l (WHO).

It responsible for about 80% of the colloid osmotic pressure of the plasma .it is a non-specific transport protein for a number of substances including fatty acids, urate, calcium, bilirubin and various drugs e.g. salicylates.
Elevation of serum albumin (hyperalbuminemia) is very unusual other than in dehydration. However, hypoproteinemia is almost always due to hypoalbuminemia. Causes of Hypoalbuminemia 1. Haemodilution as a result of taking blood from the arm receiving infusion or administering excess protein-free fluid or fluid retention.

2.Low protein intake.

3.Inadequate digestion or absorption of protein resulting in an inadequate supply of dietary amino acids. E.g. chronic pancreatic disease, severe intestinal disease. 4.Impaired synthesis of albumin e.g. in acute and chronic liver disease. 5.Increased catabolism of protein e.g. thyrotoxicosis, Cushings syndrome, diabetic coma.

6.Increased protein loss e.g. direct loss from bloodstream by haemorrhage, burns, exudates, or leakage into the gastrointestinal tract in protein-losing enteropathy or in nephrotic syndrome in which there is a marked decrease in serum albumin from direct loss into the urine.

7.Hereditary diseases e.g. analbuminemia (virtual absence), clinical consequences such as oedema are slight;
Bisalbuminemia presentsTwo chemical types of albumin are present. They give two electrophoretic peaks. There are usually no clinical symptoms.

The main effect of albumin deficiency is oedema which may develop when plasma albumin concentration falls below 2025g/l.

Also, hypoalbuminemia by reducing the binding capacity of albumin may increase the free levels of substances such as bilirubin, free fatty acids and a number of drugs thus causing toxicity even if these substances are present in rational levels.
Measurement of plasma albumin concentration is a valuable index of the severity of protein energy malnutrition in children.

1-GLOBULINS
1. 1-Antitrypsin It is the principal 1-globulin with a molecular weight of 50,000. It is a major inhibitor of proteolytic activity. Several allelic genes code for 1-antitrypsin, the alleles being given the general description Pi (protease inhibitor).
The different allelic forms of 1-antitrypsin differ structurally and individuals with different phenotypes tend to produces varying amounts of 1-antitrypsin. People who are homozygous for the PiZ allele (i.e. zz type) produce only about 15% of the levels of 1-antitrypsin in normal individuals.

The is congenital and may be associated with two diseases:

1. Pulmonary Emphysema: - This results from the

deficiency of 1-antitrypsin

unopposed action of proteases in the lung which destroys elastic tissue. Smoking seems to be a predisposing factor in the development of the emphysema.
2. Hepatic disorders: - A number of children with 1antitrypsin deficiency (i.e. the ZZ type) develop neonatal hepatic. Although the jaundice may resolve, there is usually progression to hepatic cirrhosis. Probably in about 20% of children with cirrhosis, the hepatic disorder is attributed to 1-antitrypsin deficiency.

A diagnosis of 1-antitrypsin deficiency is usually made by the absence or reduction in the 1-globulin band on electrophoresis. PiMZ heterozygotes have 60% serum 1-antitrypsin of normal. There is only a slight increase in the tendency for these individuals to develop lung disease when compared with the normal PiMM homozygotes. Neither homozygotes for the other relatively common alleles, F and S (i.e.PiFF and PiSS) nor hetrozygotes (PiMF, PiMS) appear to be at increased risk of developing liver or lung disease, although PiSZ heterozygotes seem to show more susceptibility.

Increased plasma 1-antitrypsin concentration occurs in pregnancy, in acute infections or acute inflammatory states and in trauma. -FETOPROTEIN It has a molecular wt of about 64,000 and contains about 4% COOH. It is present in foetal and maternal blood, especially in amniotic fluid. It is formed chiefly in the foetal liver. Its concentration in infants serum diminishes steadily over 2 years, reaches the lowest level of 2.6 + 1.6mg/l where it remains throughout the adult life but may increase in old age.

Clinical Significance
In obstetrics, determination of AFP levels in amniotic fluid or maternal; serum is utilized for antenatal screening for neural tube defects (NTD) in the foetus. In NTD, AFP leaks from the plasma through the open tube into the amniotic fluid so that; the fluid has grossly elevated AFP levels in open spina bifida and anencephaly. Intra uterine deaths, congenital nephrosis, teratoma, and some other fetal deaths also contribute to increases in AFP. From amniotic fluid, some AFP passes into maternal circulation where the levels will rise above the very low adult concentration.

In about 85% of cases of open spina bifida and anencephaly, maternal AFP concentrations become diagnostic at 16-18 weeks of pregnancy. AFP level is a tumour marker for cancer

Later in life gross elevations of AFP serum levels are found in about 80% of patients with hepatocellular carcinoma, in 50% of those with germ cell tumours (teratoblastomers) and in all children with hepatoblastoma.
Sequential assays are particularly useful for prognosis and monitoring treatment.

A lesser elevation of AFP occurs in some cases of carcinoma of the pancreas, gut or lung and in non-malignant diseases such as viral hepatitis, chronic active hepatitis, alcoholic cirrhosis of the liver but not (extra hepatic obstruction), tyrosinemia, Chrons disease, ulcerative colitis, pregnant women with diabetes or rhesus immunization. Methods of analysis: For amniotic fluid: - RID or rocket immunoelectrophoresis. For serum:- RIA and ELISA (EIA) may be used. For hepatic disease such as hepatocellulary carcinomas, countercurrent electrophoresis is used. This application is useful in those parts of the world where hepatocellular carcinoma is present.

1 ACID GLYCOGEN (AAG) OR OROSOMUCOID

AAG is synthesized mainly in the liver. Some tumours are able to synthesize AAG under certain well-defined conditions. It has a molecular weight of about 40,000; 45% of it is carbohydrate with hexose, hexosamine and sialic acid in equal amounts.

Although the exact role of AAG is associate with inflammation, since increased levels are observed following an acute inflammatory episode; i.e. AAG is san acute phase reactant.

There is also evidence that it plays a role in inactivating progesterone. The clinical value of AAG determination is currently limited to monitoring the acute phase reaction. However, increases also occur in rheumatoid arthritis, systemic lupus erythromatosis, Crohns ileitis, malignant neoplasms (especially those with metastases and large tumour mass) and in myocardial infarction. Decreases occur in malnutrition, severe hepatic damage, and severe protein-losing gastroenteropathies. Immunochemical methods such as RID and nephelometry are most commonly employed in the analysis of AAG

Other alpha 1 globulins include transcortin (70 mg/l) a corticosteroid binding globulin ; thyroxine binding globulin (10-20mg/l ; retinol binding protein (30 mg/l) for the transport of Vit A, prothrombin (60 mg/ml)

PREALBUMIN AND RETINOL BINDING PROTEIN Prealbumin (PA) Mol wt 54,000 and retinol binding protein (RPB) mol wt 21,000 are both synthesized in the liver.Both are transport proteins
During electrophoresis, they both migrate ahead of albumin. Their t is extremely short, probably less then 12 hrs.

Thus the measurement of serum levels gives more timely and sensitive assessment of protein malnutrition or liver dysfunction than transferrin or albumin. BothPA and RBP are transport proteins. PA binds thyroxine and triidothyronine, the latter to a lesser extent. RBP in the form of a 1:1 complex with PA transports vitamin A (Retinol) at the target cell uptake of retinol is followed by dissociation of the RBP-PA complex to its separate proteins. PA is a negative acute phase protein/reactant; the serum level falls in inflammation and malignancy and also cirrhosis of the liver of the liver and protein-wasting diseases of the gut or kidney due to decreased synthesis.

In Hodgkins disease however, the level rises. Serum RBP rises in chronic renal disease especially if there is tubular proteinuria.

Decreases are associated with liver diseases and protein malnutrition. Zinc is required for RBP synthesis and so zinc deficiency states are characterized by low serum levels of both RBP and total vitamin A.

2- GLOBULINS
1.2-Macroglobulin This is the major protein migrating in the 2- globulins region on electrophoresis. It constitutes one-third of the 2globulins and has a high molecular weight of about 820 daltons.

Although its function is uncertain, it is known to bind certain enzymes in plasma such as the mitochondrial isoenzyme of aspartate aminotransferase. It also binds protease including trypsin, chymotrypsin, plasmin and thrombin.

Its concentration varies with age being highest between 1 and 3years and decreasing over 20 years to reach values of 2.06 g/l in women and in 1.73g/l in men. Masked increase in plasma 2-macroglobulin concentration is observed in pregnancy, nephritic syndrome and some of the collagen disorders. 2. Haptoglobin Haptoglobin is a 2- globulin and is a haemoglobin binding acute phase proteins found in all vertebrates. It demonstrates considerable genetic polymorphism; the molecule consists of pairs of two types of subunits alpha and beta. The beta chains are considerably constant, with a molecular weight of 36,000 whiles there are three alleles for the alpha chain.

However as far as is known, these different proteins are functionally similar and their existence is of no clinical significance. The three different types are: 1.1S molecular weight 9,000, 2. 1F molecular weight 9,000, 3.2 molecular weight 16,000 1S and 1F are identical except for a single amino acid but the 2 type has probably resulted from the partial union of 1S and 1F chains.

Haptoglobin binds to free haemoglobin released into the plasma binding intravenous haemolysis and transports it into the lymphoreticular system where the Haptoglobinhaemoglobin complexes are removed and the concentration of Haptoglobin falls correspondingly. Thus a low serum Haptoglobin level is indicative of intravascular haemolysis. In the event of intravascular haemolysis free haptoglobin may become undetectable. Low levels due to decreased in synthesis are also seen in chronic liver disease, metastatic disease and severe sepsis.

The binding of Haptoglobin to haemoglobin to and its subsequent transportation helps to conserve the bodys iron stores which will otherwise have been lost in the urine because uncomplexed haemoglobin (Molecular weight 68,000) is filtered across the glomeruli.

Haptoglobin is an acute phase reactant and its concentration also increases in hypoalbuminanaemic states such as nephrotic syndrome.

3. Caeruloplasmin
Caerulopalsmin an acute stage phase reactant with a molecular weight 150,000. It is the principal copper containing protein which normally binds to about 90% of the copper present in plasma. It possesses an oxidative property but it is not known whether this enzymic property is of any physiological importance.

Plasma Caeruloplasmin concentration is low in the nephritic syndrome in patients with malnutrition and in Wilsons disease.

Wilsons disease is a rare congenital disorder which is characterized by : Reduced Serum Caeruloplasmin level Increased urinary excretion of copper A decreased plasma copper An increased copper content in the liver.

The characteristic symptoms of Wilsons disease are: Neurological symptoms due to basal ganglia degeneration Liver damage leading to cirrhosis Renal tubular damage on chromosome 13q,ATP7B

Kayser-Fleischer rings at the edges of the cornea due to the depletion of copper in the cornea.

Plasma Caeruloplasmin is increased in chronic liver disease. Primary biliary cirrhosis in women taking contraceptive pills and occasionally in late pregnancy.

-GLOBULIN
1. Transferrin It has a molecular weight of about 80,000. This is a -globulin which transports iron from the sites of the absorption and red cell breakdown to the iron stores and the developing red cells in the bone marrow.

In the stores the iron is laid down as ferritin and haemosiderin. Transferrin is capable of binding about 54 mol/l of iron but it is usually about a third saturated i.e. 18 mol/l.

Atransferinaemia is a rare congenital deficiency of transferrin Acquired transferrin deficiency occurs in protein-losing conditions, infections and neoplastic disease. Increased plasma transferrin concentration occurs in iron deficiency states and in women taking oral contraceptives.

2.LIPOPROTEINS They consist of a core of hydrophilic lipids surrounded by polar lipids phospholipids and then a shell of apoproteins. The Lipoproteins vary in size density, electrophoretic mobility and other characteristics.
Hyperlipoproteinaemia is almost always accompanied by hyperlipidaemia.

PLASMINOGEN AND PLASMIN

Plasminogen is a beta globulin which is synthesized in the liver and circulated in the blood and extra vascular fluid. It is converted to plasmin when some arginyl bands are hydrolyzed. This conversion is in response to activators which are present in tissues , plasma and urine

The physiological role of plasmin is the hydrolysis of fibrin into soluble products in order to restore normal blood circulation after the repair of an injured blood vessel.

CARCINOEMBRYONIC ANTIGEN (CEA)

The (CEA) protein is normally present in foetal cells but it is not detectible in adult cells in health. It reappears in the cells of intestinal neoplasms probably due to the loss of normal membrane.

Small amounts of CEA can normally be detected in plasma (up to 2-5ug/l) by sensitive immunoassay techniques. Measurement of plasma (CEA) is useful as tumor marker in definable circumstances particularly in colorectal or bronchial carcinomas.

There is however a considerable overlap between plasma (CEA) observed inpatients with inflammatory diseases and in benign and malignant tumours.

Also plasma (CEA) increases as a result of smoking. It is thus recommended that they should not be used in isolation to establish diagnosis of cancer.
However in a patient with symptoms, if plasma (CEA) is increased to more than five times the upper reference value (i.e. over 25ug/l). This is considered to be strong evidence pointing to the presence of cancer.

FIBRINOGEN This is detected as a discrete band in the - - globulin region if plasma rather than serum is used for electrophoresis. It is a protein with a molecular weight of about 500,000 which is synthesized in the liver.

Excess fibrinogen accelerates the erythrocyte sedimentation rate (ESR) and increase plasma viscosity. Plasma fibrinogen concentration is elevated in almost all cases in which ESR is increased particularly in acute infections and in pregnancy.

There is also an increase in patients with carcinoma, as a result of irradiation therapy, and often in the nephritic syndrome.

Plasma fibrinogen concentration is usually decreased in severe liver disease or in pregnancy as a complication of detachment of the placenta due to release of placental thromboplastin into the maternal circulation.

Idiopathic (pathologic state of unknown or spontaneous origin) afibrinogenaemia is a rare congenital anomaly.

-GLOBULINS

Immunoglobulins Immunoglobulins (Igs) are a group of proteins that function as antibodies recognizing and binding foreign antigens. This facilitates the destruction of those antigens by elements of the cellular immune system.
Since every immunoglobulin molecule is specific for one antigenic determinant, there are vast numbers of different Igs. All share a similar basic structure consisting of two identical heavy polypeptide chains and two identical light chains linked together by disulphide bonds/ bridges.

There are five types of the heavy chain (, , , and ) and two types of light chain( and ) peptide bonds; the Ig chain being determined by the type of heavy chain that the molecule
contains.

Thus the immunoglobulin classes are designated as IgG, IgA, IgM, IgD and IgE respectively depending on the nature of their heavy chain. On electrophoresis, the Igs behave as -globulins but IgA and IgM may migrate with the - or 2-globulins. Because the normal serum concentration of IgG is much higher than that of the other Igs,the -globulin band seen on electrophoresis of normal serum is largely due to IgG.

Abnormal Ig concentration in the plasma may be either physiological or pathological in origin. HYPOGAMMAGLOBULINEMIA

Physiological Causes At birth IgA and IgM levels are low rise steadily thereafter but IgA may not reach the normal adult level until at the end of the first decade. The levels of IgG are high at birth since it crosses the placenta into the uterus during the last trimester of pregnancy. After birth the IgG concentration declines as the maternal IgG is cleared from the body and then rises again as the infant begins to makes its own IgG.

Physiological hypogammaglobulinemia is one of the reasons for the susceptibility of infants (especially the premature) to infection. Pathological Causes A number of disorders of Ig synthesis are known ranging in severity from X-linked agammabglobulinemia (Brutons disease) in which there is virtual absence of Igs and affected children develop recurrent bacterial infections; to milder dysgammaglobulinemia in which there is defect or partial defect in one or two of the Igs. The commonest of these, IgA deficiency, has an incidence of about 1 in 400.

Hypogammaglobulinemia may also be acquired (i.e. secondary). It commonly occurs in haematological malignancies, such as chronic lymphatic leukemia, multiple myeloma, Hodgkins disease.

It could be a complication of the use of cytotoxic drugs and is characteristic of severe protein-losing states, e.g. the nephrotic syndrome. Measurement of the specific class of Ig is essential for the diagnosis of hypogammaglobulinemia. Electrophoresis is not adequate for this purpose due to the fact that apart from IgG, the other Ig levels are very low and the effect of any disease in the -globulin peak will be too small to be detected. However IgG deficiency can be inferred if the -globulin band is faint.

HYPERGAMMAGLOBULINEMIA Two broad categories are recognized: diffuse or polyclonal discrete or monoclonal -globulin increase (i.e.paraproteins)

Diffuse or Polyclonal Hypergammaglobulinaemia This is observed in autoimmune disease such as rheumatoid disease and systemic lupus erythromatosis (SLE) in chronic liver diseases, some of which have an autoimmune basis, sarcoidosis, parasitic disease and collagen.
Monoclonal or Paraproteins A paraprotein is an Ig produced by a single clone of B-cells. Since all the molecules are identical the paraprotein is seen as a discrete band usually in the -globulin region on electrophoresis.

The band may migrate elsewhere particularly if the protein is an IgA or IgM, or if there is a complex formation with another protein. More than one paraprotein may occasionally be observed. This may be due to dimerization as it often occurs with IgA paraproteins or to the presence of complexes and fragments of paraproteins in addition to the intact molecule. If plasma is used for the electrophoresis, the presence of a fibrinogen band may mimic or mask a paraprotein. Paraproteins are features of malignant diseases of B-cells, the most common being multiple myeloma.

Others include Walden Stroms macroglobulinemia (the paraprotein is an IgM) and Franklins (heavy chain) disease (this is usually an -chain, but may also be a - or -chain). Paraproteins are occasionally seen in other malignancies of B-cell origin such as chronic lymphatic leukemia.

Apart from serum, paraproteins can also be detected in urine. In about 20% of myeloma cases, the tumour produces light chains only. Since these are of low molecular weight they are cleared rapidly from the blood stream and may be undetectable in serum. They are however detectable in urine; the Ig light chains found in urine are known as Bence-Jones protein and it occurs in about 50% of all cases of myeloma.

Paraproteins can also be benign, i.e. not associated with malignant disease. The incidence of benign paraproteins increases with age and has been reported to be as high as 3% in people over the age of 70.

PROTEINS IN URINE The glomeruli of the kidney behave as ultrafilters for the plasma proteins. The glomerular filteration of protein is inversely proportional to its size. Filteration is also influenced by the shape of the molecule. In general, transport of protein molecule through the glomerular membrane progressively diminishes as protein size increases.

Normally proteins with molecular weight of more than 70,000 are not filtered. Relatively small yet significant amounts of protein (mainly albumin of molecular weight of 66,000) appear in normal urine but this concentration (about 40-150 mg/24hrs) cannot be detected by simple tests

Increased permeability of the glomeruli is therefore first indicated by increased amounts of albumin in urine, and increasing permeability is indicated by the appearance in urine of proteins with increasingly greater molecular weight. Diminishing or diminishing tubular reabsorption is indicated by the appearance of increasing concentrations of small molecular weight proteins in urine.

There are 4 ways in which proteinuria can occur: increased glomerular filteration (glomerular proteinuria), defective tubular reabsorption (tubular proteinuria), overflow from plasma to urine of an abnormal low molecular weight plasma proteins (overload proteinuria) and production of protein by the urinary tract (post-renal proteinuria).

Glomerular proteinuria is by far the most common as well as dangerous type of proteinuria. Most of the filtered protein is albumin; glomerular proteinuria is therefore often called albuminuria.

Increase in glomerular permeability occurs in numerous conditions characterized by diffuse injury to the kidney such as diabetes mellitus, immune complex disease which often affects the glomerulus in nephritis associated with systemic lupus erythematosis and in most cases of glomerulo nephritis (Nephrotic syndrome).

Tubular proteinuria results from defective reabsorption of the smaller plasma proteins that always pass through the glomerular filters such as 2-microglobulin, retinol binding protein, 1-microglobulin, and 1-acid glycoprotein. A bit of albumin is also excreted.

Acute tubular proteinuria may occur in severe disturbances of metabolism that are associated with burns, acute pancreatitis or administration of nephrotoxic drugs and fanconi syndrome. Overload proteinuria includes haemoglobinuria and Bence-Jones proteinuria which occurs as a result of a high level of an Ig light chain paraproteins (e.g. multiple myeloma).

Post-renal proteinuria is proteins which arise from the urinary tract below the kidneys and is usually due to inflammation or malignancy.