Cold Agglutinin Disease

  • Diagnosis
  • Background
  • Lab Tests
  • References
  • Related Topics

Indications for Testing

Hemolytic anemia, particularly in presence of lymphoproliferative disorder

Laboratory Testing

  • Establish hemolysis
    • CBC with peripheral smear – demonstrates anemia and hemolytic anemia
    • Reticulocyte count – usually elevated
    • Positive indicators of hemolysis – hyperbilirubinemia, increased lactate dehydrogenase
  • Direct Coombs
    • Establish presence of immunoglobins and complement degradation products on red blood cell (RBC) surfaces
    • Positive test alone does not establish autoimmune hemolytic anemia – 0.007-0.01% of unaffected population is positive
  • Serum cold agglutinin titer at 4°C – typically ≥1:64
    • Low levels may also be found in healthy adults and those with peripheral vascular disease or nonlymphoid neoplasm
    • Clinical hemolysis may occur with low titers (1:64) – usually titers ≥1:1,000
  • Once hemolysis diagnosed, evaluate for associated secondary diagnosis
    • Complement assessments – C3, C4, CH50
    • Quantification of IgG, IgA, IgM
    • Other testing based on clinical presentation

Differential Diagnosis

Cold agglutinin disease is a form of autoimmune hemolytic anemia caused by cold-reacting antibodies and classified as either primary (idiopathic) or secondary (due to an underlying disease).


  • Incidence – <1/100,000 in U.S.
  • Age – most common ≥60 years
  • Sex
    • M<F, 0.55:1 
    • Some report a slight female predominance in older populations


  • Primary cold agglutinin disease – usually associated with monoclonal cold-reacting autoantibodies
  • Secondary cold agglutinin disease
    • May be associated with either monoclonal or polyclonal cold-reacting autoantibodies
    • Predominantly caused by infection (tends to be polyclonal) or lymphoproliferative disorder (tends to be monoclonal)
    • Usually transient in children and young adults

Risk Factors


  • Accounts for ~25% of autoimmune hemolytic anemias (Berentsen, 2015)
  • Termed "cold agglutinin" because the antibodies cause affected human red blood cells (RBCs) to agglutinate at 4ºC
  • Cold-reacting autoantibodies are usually IgM, occasionally IgG, and rarely IgA
    • Polyclonal – presence of kappa and lambda light chains
    • Monoclonal – single type of light chain, usually kappa
  • Immunoglobulin-mediated deposition of complement on RBC membranes leads to complement-mediated hemolysis

Clinical Presentation

  • Fatigue and malaise due to hemolytic anemia – often the sole manifestation
  • Dermatologic – acrocyanosis, Raynaud phenomenon, livedo reticularis
  • May present as part of a paraneoplastic syndrome
Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Direct Coombs (Anti-Human Globulin) with Reflex to Direct Antiglobulin-Mono 0014008
Method: Hemagglutination

Cold Agglutinins 0050175
Method: Semi-Quantitative Hemagglutination

Complement Components 3 and 4 0050149
Method: Quantitative Immunoturbidimetry

Complement Activity Enzyme Immunoassay, Total 0050198
Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay

Immunoglobulins (IgA, IgG, IgM), Quantitative 0050630
Method: Quantitative Nephelometry

General References

Berentsen S, Beiske K, Tjønnfjord GE. Primary chronic cold agglutinin disease: an update on pathogenesis, clinical features and therapy. Hematology. 2007; 12(5): 361-70. PubMed

Berentsen S, Randen U, Tjønnfjord GE. Cold agglutinin-mediated autoimmune hemolytic anemia. Hematol Oncol Clin North Am. 2015; 29(3): 455-71. PubMed

Berentsen S, Tjønnfjord GE. Diagnosis and treatment of cold agglutinin mediated autoimmune hemolytic anemia. Blood Rev. 2012; 26(3): 107-15. PubMed

Swiecicki PL, Hegerova LT, Gertz MA. Cold agglutinin disease. Blood. 2013; 122(7): 1114-21. PubMed

Valent P, Lechner K. Diagnosis and treatment of autoimmune haemolytic anaemias in adults: a clinical review. Wien Klin Wochenschr. 2008; 120(5-6): 136-51. PubMed

Medical Reviewers

Last Update: August 2017