Patients Guide to Cryoglobulinemia Testing

Testing for cryo is a very delicate process and not every lab is equipped to do it, just like not every lab technician is familiar with the strictly prescribed protocol of how to properly draw the blood for the test. Here is a guide so you can familiarize yourself with the process and become your best advocate in the lab! Only a correctly done test can lead to correct treatment!

Cryoglobulinemia Blood Collection Supplies

Below text directly from Lee Altenberg’s website
Specimen Collection and Handling: Cryoglobulins come out of solution below body temperature. Serum must be obtained from clotted blood maintained at body temperature, from time of withdrawal. If blood is kept at lower temperatures, the cryoprecipitate may centrifuge out with the blood clot. The following procedure must be followed or the specimen is NOT acceptable. CAUTION: Specimen is not acceptable when drawn on a patient receiving heparin or any other anti-coagulant. When a Dialysis/Apheresis patient has a catheter with heparin, 10 ml or more must be wasted (discarded) before specimen for Cryoglobulin is drawn. 
Peripheral stick is preferred. 
(Heparin is anti-Complementary and will therefore breakdown the Cryo immune complexes which contain complement producing a false negative or reduced Cryocrit.) 
Other anti-coagulants chelate Ca and deplete complement Prepare transporting chamber: Select a receptacle that will maintain a fairly constant temperature. 
(Patient’s styrofoam pitchers with lids work very well) Insert a thermometer, QC’d at 37°C, through the lid. Add body temperature water to the receptacle. 
Start with water at 39°-41°C, so the temperature will not be below 37°C when received in the lab. Use vacutainers, not glass syringes, to draw the blood. Collect 20ml in red tops and place immediately into transporting chamber. If other tests are to be run in Immunopath, place all of the blood into the 37°C chamber. Deliver to lab immediately. Reject any specimen which does not comply with all of the criteria listed above. The specimen must be redrawn and must comply with all requirements.

Simple Explanation

“Cryoglobulin testing involves collecting a blood sample in a prewarmed tube and keeping the sample at or near body temperature during test preparation. The person’s serum is then refrigerated for 72 hours and examined daily for precipitates. If there are any present, then the quantity is estimated and the sample is warmed to determine whether the precipitates dissolve. If they do, then cryoglobulins are present”.

How do I Advocate for Accurate Testing?

There re are many psychological, cultural and personal reasons people have a hard time advocating for themselves.  You cannot control everything but you can participate in the process to increase your odds for accurate testing.  Here are a few tips to help prepare you!

  • Remember you are worth it!

  • Imagine you are a first grade teacher.  Be polite, clear and firm. Assume that the person you are talking to comes from a good place and just needs education.

  • A smile goes a long way in person or on the phone.  If you are frustrated while talking on the phone try smiling.  If that is challenging try looking in a mirror and smiling.  A smile can change the tone of our voice to a more pleasant one, which makes it easier to get answers.

  • Advocating is not the same thing as being aggressive, grumpy or demanding.  Avoid being condescending.

  • If you are unsure about something ask for clarification. It is okay to ask for a supervisor if your needs are not getting met.

  • Be willing to be vulnerable.  Try phrases like: I was wondering if you could help me.

    • I have been sick and am really ‘anxious’ that the test be done right so my doctor can help me feel better.

  • Try deflecting or diffusing the situation by saying you have to your homework (accurate testing) assigned by your doctor.  For example:

    • My doctor told me to make sure of that this checklist is followed when I get my lab test done.

    • I have this checklist so I can report back to my doctor.

  • Bring a written list of questions and testing protocols with you or have ready before you make a phone call.

  • Imagine that the questions you need answered are to help someone else.  Many parents find it easier to advocate for their children than themselves. Or try picturing your closest friend or family member who wants you as well as possible.  If you can’t do it for yourself then do it for them! Remember you need the answers for someone you love (yourself!)

Lee Altenberg, Ph.D. explains CryoCrit.

Measuring the Cryocrit in Cryoglobulinemia

Comments by Lee Altenberg. Revised August 8, 2014 – Quoted directly from Lee Altenberg, Ph.D website.
“Because cryoglobulins are thermally unstable, any test that measures the quantity of cryoglobulins in the blood must be performed immediately at the place where the blood is sampled. Tests to measure cryoglobulins can only be sent out to another lab if the lab that drew the blood from the patient immediately separated the serum from the blood cells before sending it out. Otherwise, even if an outside laboratory claims to measure cryoglobulins, any samples sent to it will be invalid because they cannot be processed according to the necessary steps (below). In that case, not only will the quantities of cryoglobulins measured be incorrect, but the test may completely fail to even detect cryoglobulins. Without accurate measurement of cryoglobulin levels, no correct assessment can be made of a patient’s treatments.

Therefore, cryoglobulinemia patients must be sure that the lab where their blood is drawn can itself separate the blood cells from the serum at 37°C. Unfortunately, because of the rarity of cryoglobulinemia, most physicians are unaware of the requirements for valid cryoglobulin tests. Fortunately, the Cryocrit test can be performed with the equipment that most any medical testing laboratory has, and should cost only about $20 per test. The only item that may not be immediately available is a 37°C incubator to put the centrifuge inside of. Instead, the centrifuge can be placed in a 37°C walk-in room.”

Below are the instructions used by a hospital that treats many cryoglobulinemia patients (the supervisor of the laboratory requested that the identity of the hospital not be divulged, as the questions they have received regarding cryocrit measurements have been burdensome).

What is the Basic Checklist for Cryo Blood Collection?

BASIC Details for blood collection:

  • Ask for the person you spoke with or the person who has had experience collecting blood for this test. Or ask for a supervisor to do the collecting.

  • Remind the phlebotomist that the vial needs to go directly into the ‘warm bath’.

    • If multiple vials are drawn at the same time then suggest a colleague take the cryo vials to the ‘warm bathe’ by while they finish collecting the other vials.

  • Make sure blood is drawn from a vein and not a catheter that has heparin in it.

  • Make sure your blood is collected via a vacutainer.

  • Ask that the vial (container) the blood is collected into come from the ‘warm bath’.

    • At the very least make sure the vial is room temperature.

    • Sometimes vials are stored near an AC vent or on a fridge or freezer.  This alone can invalidate the test so make sure the vial is room temperature before your blood is drawn.

    • Many of us have cold hands that are not warm enough to warm the vial up.  Ask the phlebotomist for help in ensuring accuracy.

What is the Pre-Checklist before I get my Cryo Testing done?

BASIC Pre-Checklist  

Below is a basic checklist for patients seeking a cryoglobulinemia test.

  • Call the laboratory and ask to speak to the clinical or medical laboratory manager.

    • You want someone who was/is a phlebotomist, nurse or has other medical training not someone who is solely an administrator or manager.

  • Ask if the manager if they or their staff have collected blood for a cryoglobulinemia test in this lab.

    • Whether they have or have not collected for this test then

      • Ask them if they can explain the process to you (you can check this against your list) before they draw blood.

      • Or ask them if you could review the checklist with them before they draw blood.

  • Ask if they have a ‘warm bath’ or other controlled temperature vessel to put the test vial into after collection.  The blood sample needs to be put into a 37°C bath.

    • Ideally collection should happen at the site that has the 37°C ‘warm bath’.

    • When in the hospital I ask to go to the lab for my blood to be drawn so that the sample can go directly into the ‘warm bath’.

    • If you can’t go to the lab then a transporting vessel must be prepared to transport the sample.

  • Ask the manager if they process the test in-house.

    • It is best if they process in-house but many labs send out the test for processing. Try to find a lab that processes in-house.  This may not be possible so do not worry if you cannot make this happen.

    • Labs use different methods for transporting but temperature management is critical to get an accurate cryo test.

  • Ask if there is a specific person to see to ensure best results.

Why is Advocating for Accurate Cryo Testing so Important?

Why self-advocacy is critical in cryoglobulinemia testing?

  • Getting an accurate test may help your doctors treat you.
  • Cryoglobulinemia in any form is rare which means education about it and testing is rare.
  • Doctors who order the test may not be familiar with accurate collection and processing methods.
  • The laboratory where you get your blood drawn may never have collected blood for this test.
  • The laboratory where you get your blood drawn may send the test out for processing.
  • Phlebotomists, the people who draw your blood, may never have drawn blood for this test.
  • Phlebotomists rarely have anything to do with how a blood test is processed.
  • Specific criteria must be met to get an accurate test before the blood is even collected.
  • Specific criteria must be met to get an accurate test immediately after the blood is collected.
  • The laboratory must have the proper equipment to put the blood into or testing is invalid.