Cryoglobulin evaluation: analysis of intra-laboratory and inter-laboratory variability

Background Cryoglobulins (CRG) are immunoglobulins that precipitate in serum at temperatures below 37°C and resolubilize upon warming. The main reasons of interest of a clinical pathologist in the study of cryoglobulinemia are: 1) lack of standardisation in the preanalytical, analytical and postanalytical phases of the process (classification and reporting); 2) peculiarities of physiopathological mechanism 3) important clinical consequences. Vermeersch et al. studied these issues in 2008. To assess current practice in the detection, analysis, and reporting of cryoglobulins, a questionnaire was sent to 140 laboratories. They showed that only 36% of laboratories used standard procedures of analysis. Consequently, they concluded that standardisation was needed for cryoglobulin detection to avoid missed diagnoses and improve the comparability of results. Sargur et al. in 2010 reviewed the classification and clinical features of cryoglobulins and suggested “best practice” guidelines for laboratory detection and identification of cryoglobulins. They particularly highlighted the relevance of preanalytical and analytical phases: maintenance of the sample at a stable temperature of 37°C, especially throughout the initial steps (collection and transportation); centrifugation and separation methods; cryoprecipitate quantification; cryoprecipitate washing techniques; immunocharacterization of cryoprecipitates especially through immunofixation techniques (considered the “gold standard”). Objectives To verify and assess the variability of laboratory processes of CRG. Methods We checked laboratory databases of Hospital and University (Lab A and B) of Modena with long tradition in the cryoglobulin analysis (more than 6000 tests from 2002 to 2017). Concerning CRG testing, 734 patient samples were studied in both laboratories. We compared our results according to Brouet classification into subgroups: type I, II and III. Therefore, we evaluated intra-laboratory variability, compared to previous or more frequent results. Finally, we studied inter-laboratory variability based on non-concordant laboratory reports. Results In the following table, we have represented the comparison between labs about the same patient cohort in 734 patient samples:Conclusions No data about variability in CRG analysis are reported in literature. National and international guidelines are not explicative enough. Furthermore, many doubts about classifications are established. Our experience is unique but limited in two laboratories. Given the variability of testing conditions used in different laboratories and the lack of test standards and reference values, we confirm the need of further investigations into standardisation of CRG testing. New guidelines are fundamental, in order to optimise all phases of CRG research (pre and post analysis) and to ensure correct diagnosis and adequate treatments of the associated diseases