Erythrocyte sedimentation rate
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and keywords: Biernacki Reaction; Sedimentation rate; Westergren ESR
Overview
The erythrocyte sedimentation rate (ESR), also called sedimentation rate, sed rate, or Biernacki Reaction, is a non-specific, indirect measurement of the acute phase reactant concentration which is altered in conditions of inflammation. It is commonly used as a medical screening test. 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. 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 is, however, a physiological finding in some equidae and can be as such in felidae and suidae species, namely the horse, cat and pig respectively. The basal ESR is slightly higher in females than males and increases with age. It is also affected by the size, shape, and number of red cells, as well as by other constituents in the blood such as immunoglobulins. The ESR is increased in pregnancy, anemia, or any cause or focus of inflammation and decreased in sickle cell anemia, polycythemia, and congestive heart failure.
History
This test was invented in 1897 by the Polish doctor Edmund Biernacki.[1] 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),[2] which uses sodium citrate-anticoagulated specimens.[3]
Uses
Although it is frequently ordered, the erythrocyte sedimentation rate (ESR) is not a useful screening test. It is only useful for diagnosing three diseases: myeloma, temporal arteritis and polymyalgia rheumatica (in which it 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.
Values are increased in states of anemia,[4] and in black populations.[5]
Adults
ESR reference ranges from a large study:[6]
| (ESR 95% limits) | Age (years) | ||
| 20 | 55 | 90 | |
|---|---|---|---|
| Men | 12 | 14 | 19 |
| Women | 18 | 21 | 23 |
As an alternative the following formula may be used to give predicted values for ESR based on age and gender:[7]
Children
- Newborn: 0 to 2 mm/hr.
- Neonatal to puberty: 3 to 13 mm/hr.
- Newborn: 0-5 mm/hr.
- Neonatal to puberty: 0-15 mm/hr.
Causes of increased erythrocyte sedimentation rate
Common Causes
- Ageing
- Anemia
- Infection
- Inflammation
- Macrocytosis
- Malignancy
- Pregnancy
- Renal disease
- Technical factors (dilutional problem, increased temperature of specimen, tilted ESR tube)
Causes by Organ System
Causes in Alphabetical Order[8][9]
Causes of decreased erythrocyte sedimentation rate
Common Causes
- Abnormal erythrocyte morphologies
- Hyperviscosity state
- Hypofibrinogenemia
- Hypogammaglobulinemia
- Leukocytosis
- Microcytosis
- Polycythemia
- Technical factors (dilutional problem, inadequate mixing, clotting of blood sample, short ESR tube, vibration during testing)[10]
Causes by Organ System
| Cardiovascular | Congestive heart failure |
| Chemical/Poisoning | No underlying causes |
| Dental | No underlying causes |
| Dermatologic | No underlying causes |
| Drug Side Effect | No underlying causes |
| Ear Nose Throat | No underlying causes |
| Endocrine | No underlying causes |
| Environmental | No underlying causes |
| Gastroenterologic | No underlying causes |
| Genetic |
Abetalipoproteinemia, Bruton's agammaglobulinemia, Chorea acanthocytosis, Congenital afibrinogenemia, Polycythemia, Sickle cell disease,Hereditary spherocytosis |
| Hematologic |
Abetalipoproteinemia, Acanthocytosis, Anisoctyosis, Bruton's agammaglobulinemia, Chorea acanthocytosis, Congenital afibrinogenemia,Dysproteinemia, Hereditary spherocytosis, Hyperviscosity state, Hypofibrinogenemia, Hypogammaglobulinemia, Leukocytosis, Macrophage-activation syndrome, Microcytosis, Polycythemia, Sickle cell disease, Spherocytosis |
| Iatrogenic | No underlying causes |
| Infectious Disease | Leukocytosis |
| Musculoskeletal/Orthopedic | No underlying causes |
| Neurologic | Chorea acanthocytosis |
| Nutritional/Metabolic | Abetalipoproteinemia |
| Obstetric/Gynecologic | No underlying causes |
| Oncologic | Dysproteinemia, Macrophage-activation syndrome |
| Ophthalmologic | No underlying causes |
| Overdose/Toxicity | No underlying causes |
| Psychiatric | No underlying causes |
| Pulmonary | No underlying causes |
| Renal/Electrolyte | Dysproteinemia |
| Rheumatology/Immunology/Allergy | Bruton's agammaglobulinemia, Dysproteinemia, Hypogammaglobulinemia, Macrophage-activation syndrome |
| Sexual | No underlying causes |
| Trauma | No underlying causes |
| Urologic | No underlying causes |
| Miscellaneous | Technical factors (dilutional problem, inadequate mixing, clotting of blood sample, short ESR tube, vibration during testing) |
Causes in Alphabetical Order
- Abetalipoproteinemia
- Acanthocytosis
- Anisoctyosis
- Bruton's agammaglobulinemia
- Congenital afibrinogenemia
- Congestive heart failure
- Dysproteinemia
- Hyperviscosity state
- Hypofibrinogenemia
- Hypogammaglobulinemia
- Leukocytosis
- Macrophage-activation syndrome
- Microcytosis
- Polycythemia
- Sickle cell disease
- Spherocytosis
- Technical factors (dilutional problem, inadequate mixing, clotting of blood sample, short ESR tube, vibration during testing)[10]
References
- ↑ Template:WhoNamedIt2 and eponymously named Template:WhoNamedIt
- ↑ Template:WhoNamedIt2 and Template:WhoNamedIt2 who are eponymously named for the Template:WhoNamedIt
- ↑ "ICSH recommendations for measurement of erythrocyte sedimentation rate. International Council for Standardization in Haematology (Expert Panel on Blood Rheology)" (Scanned & PDF). J. Clin. Pathol. 46 (3): 198–203. 1993. PMID 8463411.
- ↑ Kanfer EJ, Nicol BA (1997). "Haemoglobin concentration and erythrocyte sedimentation rate in primary care patients" (Scanned & PDF). Journal of the Royal Society of Medicine. 90 (1): 16–8. PMID 9059375.
- ↑ Gillum RF (1993). "A racial difference in erythrocyte sedimentation". Journal of the National Medical Association. 85 (1): 47–50. PMID 8426384.
- ↑ Wetteland P, Røger M, Solberg HE, Iversen OH (1996). "Population-based erythrocyte sedimentation rates in 3910 subjectively healthy Norwegian adults. A statistical study based on men and women from the Oslo area". J. Intern. Med. 240 (3): 125–31. PMID 8862121. - listing upper reference levels expected to be exceeded only by chance in 5% of subjects
- ↑ Template:GPnotebook
- ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
- ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
- ↑ 10.0 10.1 Brigden, ML. (1999). "Clinical utility of the erythrocyte sedimentation rate". Am Fam Physician. 60 (5): 1443–50. PMID 10524488. Unknown parameter
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