Erythrocyte sedimentation rate
Encyclopedia
The erythrocyte sedimentation rate (ESR), also called a sedimentation rate or Biernacki Reaction, is the rate at which red blood cells sediment in a period of 1 hour. It is a common hematology
test that is a non-specific measure of inflammation
.
To perform the test, anticoagulated blood
is placed in an upright tube, known as a Westergren tube, and the rate at which the red blood cell
s fall is 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 immunoglobulin 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
or rheumatoid arthritis
, and decreased in polycythemia
, sickle cell anemia
, hereditary spherocytosis
, and congestive heart failure. The basal ESR is slightly higher in females.
. In some parts of the world the test continues to be referred to as the Biernacki Test (Polish abbreviation: OB = Odczyn Biernackiego.) 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), which uses sodium citrate-coagulated specimens.
, temporal arteritis
, polymyalgia rheumatica
, various auto-immune diseases, systemic lupus erythematosus
, rheumatoid arthritis
, and chronic kidney diseases. In many of these cases, the ESR may exceed 100 mm/hour.
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
. It is a component of the PDCAI, an index for assessment of severity of inflammatory bowel disease in children.
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. There is also a wintrobe method.
The use of the ESR as a screening test in asymptomatic persons is limited by its low sensitivity and specificity. When there is a moderate suspicion of disease, the ESR may have some value as a "sickness index."
Westergren's original normal values (men 3mm and women 7mm) 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.
Values are increased in states of anemia, and in black populations.
ESR reference ranges from a large 1996 study with weaker confidence limits:
Typical normal ranges quoted are:
is an acute phase protein
produced by the liver during an inflammatory reaction. Since C-reactive protein levels in the blood rise more quickly after the inflammatory or infective process begins, ESR is often replaced with C-reactive protein measurement. There are specific drawbacks, however, for example, both tests for ESR and CRP were found to be independently associated with a diagnosis of acute maxillary sinusitis so in some cases the combination of the two measurements may improve diagnostic sensitivity and specificity.
Hematology
Hematology, also spelled haematology , is the branch of biology physiology, internal medicine, pathology, clinical laboratory work, and pediatrics that is concerned with the study of blood, the blood-forming organs, and blood diseases...
test that is a non-specific measure of inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
.
To perform the test, anticoagulated blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
is placed in an upright tube, known as a Westergren tube, and the rate at which the red blood cell
Red blood cell
Red blood cells are the most common type of blood cell and the vertebrate organism's principal means of delivering oxygen to the body tissues via the blood flow through the circulatory system...
s fall is measured and reported in mm/h.
Since the introduction of automated analyzers
Automated analyser
An automated analyser is a medical laboratory instrument designed to measure different chemicals and other characteristics in a number of biological samples quickly, with minimal human assistance....
into the clinical laboratory, the ESR test has been automatically performed.
The ESR is governed by the balance between pro-sedimentation factors, mainly fibrinogen
Fibrinogen
Fibrinogen is a soluble plasma glycoprotein, synthesised by the liver, that is converted by thrombin into fibrin during blood coagulation. This is achieved through processes in the coagulation cascade that activate the zymogen prothrombin to the serine protease thrombin, which is responsible for...
, and those factors resisting sedimentation, namely the negative charge of the erythrocytes (zeta potential
Zeta potential
Zeta potential is a scientific term for electrokinetic potential in colloidal systems. In the colloidal chemistry literature, it is usually denoted using the Greek letter zeta, hence ζ-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
Rouleaux
Rouleaux are stacks of red blood cells which form because of the unique discoid shape of the cells in vertebrate body. The flat surface of the discoid RBCs give them a large surface area to make contact and stick to each other; thus, forming a rouleau...
,' which settle faster. Rouleaux formation can also occur in association with some lymphoproliferative disorders in which one or more immunoglobulin 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
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
or rheumatoid arthritis
Rheumatoid arthritis
Rheumatoid arthritis is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. The process produces an inflammatory response of the synovium secondary to hyperplasia of synovial cells, excess synovial fluid, and the development...
, and decreased in polycythemia
Polycythemia
Polycythemia is a disease state in which the proportion of blood volume that is occupied by red blood cells increases...
, sickle cell anemia
Sickle-cell disease
Sickle-cell disease , or sickle-cell anaemia or drepanocytosis, is an autosomal recessive genetic blood disorder with overdominance, characterized by red blood cells that assume an abnormal, rigid, sickle shape. Sickling decreases the cells' flexibility and results in a risk of various...
, hereditary spherocytosis
Hereditary spherocytosis
Hereditary spherocytosis is a genetically-transmitted form of spherocytosis, an auto-hemolytic anemia characterized by the production of red blood cells that are sphere-shaped rather than bi-concave disk shaped , and therefore more prone to hemolysis.-Symptoms:As in non-hereditary spherocytosis,...
, and congestive heart failure. The basal ESR is slightly higher in females.
History
This test was invented in 1897 by the Polish doctor Edmund BiernackiEdmund Biernacki
Edmund Faustyn Biernacki was a Polish physician.Biernacki was the first one to note a relationship between the sedimentation rate of red blood cells in a human blood sample and the general condition of the organism. This method, known as the Biernacki Reaction, is universally practised in all...
. In some parts of the world the test continues to be referred to as the Biernacki Test (Polish abbreviation: OB = Odczyn Biernackiego.) 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), which uses sodium citrate-coagulated specimens.
Uses
Although it is frequently ordered, ESR is of limited use as a screening test in asymptomatic patients. It is useful for diagnosing diseases, such as multiple myelomaMultiple myeloma
Multiple myeloma , also known as plasma cell myeloma or Kahler's disease , is a cancer of plasma cells, a type of white blood cell normally responsible for the production of antibodies...
, temporal arteritis
Temporal arteritis
Giant-cell arteritis or Horton disease is an inflammatory disease of blood vessels most commonly involving large and medium arteries of the head...
, polymyalgia rheumatica
Polymyalgia rheumatica
Polymyalgia rheumatica , abbreviated as PMR, is a syndrome with pain or stiffness, usually in the neck, shoulders, and hips. The pain can be very sudden, or can occur gradually over a period of time...
, various auto-immune diseases, systemic lupus erythematosus
Systemic lupus erythematosus
Systemic lupus erythematosus , often abbreviated to SLE or lupus, is a systemic autoimmune disease that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body's cells and tissue, resulting in inflammation and tissue damage...
, rheumatoid arthritis
Rheumatoid arthritis
Rheumatoid arthritis is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. The process produces an inflammatory response of the synovium secondary to hyperplasia of synovial cells, excess synovial fluid, and the development...
, and chronic kidney diseases. In many of these cases, the ESR may exceed 100 mm/hour.
It is commonly used for a differential diagnosis for Kawasaki's disease and it may be increased in some chronic infective conditions like tuberculosis
Tuberculosis
Tuberculosis, MTB, or TB is a common, and in many cases lethal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis. Tuberculosis usually attacks the lungs but can also affect other parts of the body...
and infective endocarditis
Endocarditis
Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves . Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or even on intracardiac devices...
. It is a component of the PDCAI, an index for assessment of severity of inflammatory bowel disease in children.
The clinical usefulness of ESR is limited to monitoring the response to therapy in certain inflammatory diseases such as temporal arteritis
Arteritis
Arteritis is inflammation of the walls of arteries, usually as a result of infection or auto-immune response.-Types:Some disorders have arteritis as their main feature...
, polymyalgia rheumatica
Polymyalgia rheumatica
Polymyalgia rheumatica , abbreviated as PMR, is a syndrome with pain or stiffness, usually in the neck, shoulders, and hips. The pain can be very sudden, or can occur gradually over a period of time...
and rheumatoid arthritis
Rheumatoid arthritis
Rheumatoid arthritis is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. The process produces an inflammatory response of the synovium secondary to hyperplasia of synovial cells, excess synovial fluid, and the development...
. It can also be used as a crude measure of response in Hodgkin's lymphoma
Hodgkin's lymphoma
Hodgkin's lymphoma, previously known as Hodgkin's disease, is a type of lymphoma, which is a cancer originating from white blood cells called lymphocytes...
. Additionally, ESR levels are used to define one of the several possible adverse prognostic factors in the staging of Hodgkin's lymphoma. There is also a wintrobe method.
The use of the ESR as a screening test in asymptomatic persons is limited by its low sensitivity and specificity. When there is a moderate suspicion of disease, the ESR may have some value as a "sickness index."
Normal values
Note: mm/hr. = millimeters per hour.Westergren's original normal values (men 3mm and women 7mm) 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.
Values are increased in states of anemia, and in black populations.
Adults
The widely used rule for calculating normal maximum ESR values in adults (98% confidence limit) is given by a formula devised in 1983:ESR reference ranges from a large 1996 study with weaker confidence limits:
| Age | 20 | 55 | 90 |
|---|---|---|---|
| Men | 12 | 20 | 19 |
| Women | 18 | 21 | 23 |
Children
Normal values of ESR have been quoted as 1 to 2 mm/hr at birth, rising to 4 mm/hr 8 days after delivery, and then to 17 mm/hr by day 14.Typical normal ranges quoted are:
- Newborn: 0 to 2 mm/hr
- Neonatal to puberty: 3 to 13 mm/hr, but other laboratories place an upper limit of 20.*
Relation to C-reactive protein
C-reactive proteinC-reactive protein
C-reactive protein is a protein found in the blood, the levels of which rise in response to inflammation...
is an acute phase protein
Acute phase protein
Acute-phase proteins are a class of proteins whose plasma concentrations increase or decrease in response to inflammation...
produced by the liver during an inflammatory reaction. Since C-reactive protein levels in the blood rise more quickly after the inflammatory or infective process begins, ESR is often replaced with C-reactive protein measurement. There are specific drawbacks, however, for example, both tests for ESR and CRP were found to be independently associated with a diagnosis of acute maxillary sinusitis so in some cases the combination of the two measurements may improve diagnostic sensitivity and specificity.