ESR (Erythrocyte sedimentation rate)

Erythrocyte sedimentation rate

Erythrocyte sedimentation rate
Diagnostics
Westergren pipet array on StaRRsed automated ESR analyzer

The erythrocyte sedimentation rate (ESR), also called a sedimentation rate or Westergren ESR, is the rate at which red blood cells sediment in a period of one hour. It is a common hematology test, and is a non-specific measure of inflammation. To perform the test, anticoagulated blood was traditionally placed in an upright tube, known as a Westergren tube, and the rate at which the red blood cells fall was measured and reported in mm/h.

Since the introduction of automated analyzers into the clinical laboratory, the ESR test has been automatically performed.

The ESR is governed by the balance between pro-sedimentation factors, mainly fibrinogen, and those factors resisting sedimentation, namely the negative charge of the erythrocytes (zeta potential). When an inflammatory process is present, the high proportion of fibrinogen in the blood causes red blood cells to stick to each other. The red cells form stacks called 'rouleaux,' which settle faster. Rouleaux formation can also occur in association with some lymphoproliferative disorders in which one or more immunoglobulins are secreted in high amounts. Rouleaux formation can, however, be a normal physiological finding in horses, cats, and pigs.

The ESR is increased by any cause or focus of inflammation. The ESR is increased in pregnancy, inflammation, anemia orrheumatoid arthritis, and decreased in polycythemia, sickle cell anemia, hereditary spherocytosis, and congestive heart failure. It may be increased in kidney cancer. The basal ESR is slightly higher in females.^[1]

History

The test was invented in 1897 by the Polish pathologist Edmund Biernacki.^[2] In some parts of the world the test continues to be referred to as Biernacki's Reaction (Polish: odczyn Biernackiego, OB). In 1918 the Swedish pathologist Robert Sanno Fåhræus declared the same and, along with Alf Vilhelm Albertsson Westergren, are eponymously remembered for the Fåhræus-Westergren test (abbreviated as FW test; in the UK, usually termed Westergren test),^[3] which uses sodium citrate-anti-coagulated specimens.^[4]

Uses

Diagnosis

It can sometimes be useful in diagnosing some diseases, such as multiple myeloma, temporal arteritis, polymyalgia rheumatica, various auto-immune diseases, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease^[5] and chronic kidney diseases. In many of these cases, the ESR may exceed 100 mm/hour.^[6]

It is commonly used for a differential diagnosis for Kawasaki's disease and it may be increased in some chronic infective conditions like tuberculosis and infective endocarditis.

Stages in erythrocyte sedimentation:

There are 3 stages in erythrocyte sedimentation 1) Stage 1  : Rouleaux formation - First 10 minutes 2) Stage 2  : Stage of sedimentation or settling - 40 mins 3) Stage 3  : Stage of packing - 10 minutes, sedimentation slows and cells start to pack at the bottom of the tube

Disease severity

It is a component of the PCDAI (Pediatric Crohn's Disease Activity Index), an index for assessment of severity of inflammatory bowel disease in children.

Monitoring response to therapy

The clinical usefulness of ESR is limited to monitoring the response to therapy in certain inflammatory diseases such as temporal arteritis, polymyalgia rheumatica and rheumatoid arthritis. It can also be used as a crude measure of response in Hodgkin's lymphoma. Additionally, ESR levels are used to define one of the several possible adverse prognostic factors in the staging of Hodgkin's lymphoma.

Normal values

Note: mm/h. = millimeters per hour.

Westergren's original normal values (men 3 mm and women 7 mm)^[7] made no allowance for a person's age and in 1967 it was confirmed that ESR values tend to rise with age and to be generally higher in women.^[8] Values are increased in states of anemia,^[9] and in black populations.^[10]

Adults

The widely used^[11] rule calculating normal maximum ESR values in adults (98% confidence limit) is given by a formula devised in 1983:^[12]

This formula is no longer credited. Other studies show only a small dependence of ESR on age and much lower values, as seen in the following:

ESR reference ranges from a large 1996 study of 3,910 healthy adults:^[13]

Age	20	55	90
Men—5% exceed	12	14	19
Women—5% exceed	18	21	23

Children

Normal values of ESR have been quoted as 1^[14] to 2^[15] mm/h at birth, rising to 4 mm/h 8 days after delivery,^[15] and then to 17 mm/h by day 14.^[14]

Typical normal ranges quoted are:^[16]

• Newborn: 0 to 2 mm/h
• Neonatal to puberty: 3 to 13 mm/h, but other laboratories place an upper limit of 20.