Erythrocyte sedimentation rate

The erythrocyte sedimentation rate (ESR), also called a sedimentation rate, sed rate, or Biernacki Reaction, is the rate at which red blood cells precipitate in a period of 1 hour. It's a common haematology test which 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 cells 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 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 decreased in sickle cell anemia, polycythemia, and congestive heart failure. The basal ESR is slightly higher in females.

History

This test was invented in 1897 by the Polish doctor Edmund Biernacki. 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 (in the UK, usually termed Westergren test), which uses sodium citrate-anticoagulated specimens.

Uses

Although it is frequently ordered, the erythrocyte sedimentation rate (ESR) is not a useful screening test. It is useful for diagnosing diseases, such as multiple myeloma, 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 erythrocyte sedimentation rate (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.

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."

An elevated ESR in the absence of other findings should not trigger an extensive laboratory or radiographic evaluation.

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:

$\{rm\; ESR\}\; (mm/hr)\; le\; frac\; \{\{rm\; Age\}\; (in\; years)\; +\; 10\; (if\; female)\}\{2\}$

ESR reference ranges from a large 1996 study with tighter confidence limits:

(ESR 95% limits)	Age (years)
	20	55	90
Men	10	14	19
Women	15	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 protein is an acute phase protein that is a medium in the reactions by which infections cause increased ESR. Since C-reactive protein is an earlier step it also appears faster, 6-8 hours after infection. Therefore, ESR may be replaced with C-reactive protein measuring.

References