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When WM does cause symptoms, some of them can be like those seen with other types of non-Hodgkin lymphoma (NHL). WM found this way is sometimes called asymptomatic or smoldering WM. Instead, it’s found when the person has blood tests done for some other reason. Patients with smoldering WM and high serum IgM can be safely observed in the absence of any indications per the Consensus recommendations to initiate WM-directed therapy.Sometimes, Waldenstrom macroglobulinemia (WM) isn’t causing any symptoms when it’s first found. Serum viscosity at diagnosis of WM, and not IgM concentration, represents the single most important independent predictor for development of subsequent hyperviscosity-related symptoms. In summary, the occurrence of symptomatic hyperviscosity does not impact OS. Among patients with smoldering WM and IgM >6000 mg/dL at diagnosis (n = 13) who were managed expectantly, the median time-to-initial therapy was 6.9 years and only 15% developed hyperviscosity-related symptoms subsequently. On multivariate-analysis, only viscosity >1.8 cp (risk ratio: 4.0, P = 0.02) assessed at the time of WM diagnosis was an independent predictor for the development of subsequent symptomatic hyperviscosity. Overall survival (OS) of these 130 patients was similar to that of patients without symptomatic hyperviscosity (median: 11.5 vs 11.6 years P = 0.63). Of 997 WM patients evaluated from January, 1996 through June, 2017, symptomatic hyperviscosity was observed in 130 (13%) patients. Herein, we attempt to identify predictors of the development of symptomatic hyperviscosity and its impact in patients with WM. Data regarding the predictors of symptomatic hyperviscosity and outcomes related to this complication remain scarce and a recent study proposed that IgM >6000 mg/dL be considered a new criterion for initiating therapy in otherwise asymptomatic (smoldering) WM to pre-empt hyperviscosity-related injury. Monoclonal IgM can variably impact intrinsic serum viscosity, leading to widely disparate symptomatic thresholds for development of hyperviscosity-related symptoms. Symptomatic hyperviscosity is a well-established phenomenon in Waldenström macroglobulinemia (WM).