The erythrocyte sedimentation rate, 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. 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 or rheumatoid 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.
History This test was invented in 1897 by the Polish
doctor Edmund Biernacki. In some parts of the world the test continues to be referred
to as Biernacki's Reaction 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, which uses sodium citrate-anti-coagulated specimens.
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 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. 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 packin - 10 minutes, sedimentation slows and cells start to pack at the bottom of the
tube Disease severity
It is a component of the PCDAI, 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 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 calculating normal maximum ESR values in adults is given by a formula
devised in 1983:
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:
Children Normal values of ESR have been quoted as 1
to 2 mm/h at birth, rising to 4 mm/h 8 days after delivery, and then to 17 mm/h by day
14. Typical normal ranges quoted are:
Newborn: 0 to 2 mm/h Neonatal to puberty: 3 to 13 mm/h, but other
laboratories place an upper limit of 20. Relation to C-reactive protein
C-reactive protein 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.
Several studies investigated the differential diagnostic values of ESR and CRP in inflammatory
disease, and concluded ESR is a potential meaningful biomarker for disease differentiation.
References
External links Mediscuss on ESR
American Family Physician article on ESR ESR at Lab Tests Online