GHOR ALSAFI LAB.

ESR

ESR
(Erythrocyte Sedimentation Rate)

**. Introduction:

The ESR is one of the oldest laboratory tests still in use. Although some of its usefulness
has decreased as more specific methods of evaluating disease (such as C-reactive protein
– CRP) have been developed, new clinical applications have been reported.

The reference method for measuring ESR is that of Westergren.

**. Normal Reference Ranges:

* Upper Limits of Reference Ranges for ESR (mm/hour) Westergren Method
Age Upper Limits for ESR (mm/hour)
Males
Females
Below 50 years 20 mm/hour 15 mm/hour
Above 50 years 30 mm/hour 20 mm/hour
Above 85 years 42 mm/hour 30 mm/hour

The ESR gradually increases with age and this likely reflects higher disease prevalence in
the elderly.

In the newborn, the ESR is usually low.

In childhood and adolescence, the ESR is the same as for normal adult males with no
differences between boys and girls.

**. Clinical Significance:

ESR is used for screening for acute or chronic inflammatory diseases and for monitoring
the response of such diseases to therapy.

The ESR is of little value in screening asymptomatic patients for disease.

In pregnancy, the ESR increases.

ESR is markedly increased in: multiple myeloma and hyperfibrinogenemia.

ESR is moderately increased in: rheumatoid arthritis, tuberculosis, chronic infections and
cancers. The ESR has little diagnostic values in these disorders, but can be useful in
monitoring disease activity.

Because the test is often normal in patients with cancer and infections, a normal ESR
cannot be used to exclude these diagnostic possibilities. However, in patients with known
cancer, when the value exceeds 100 mm/hour, metastases are usually present.

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 GHOR ALSAFI LAB. ESR

**. Preanalytical Conditions:

1. Collection of Specimen:

Venous blood is collect into a citrated tube.

The blood may be collected into EDTA tube and afterwards added to the citrate.

2. Storage Considerations:

Sample is stored at room temperature and analyzed within two hours of collection.

The ESR value is reduced in blood stored for longer periods even if storage was carried
out at 40C.

**. Factors Involved in Erythrocyte Sedimentation:

1. Plasma Factors:

Fibrinogen is the acute phase protein that is primarily responsible for an increased ESR.
The negative charge on erythrocytes tends to keep them apart and fibrinogen decreases
this negative charge. This promotes the formation of rouleaux, which sediment more
rapidly than single cells.

The presence of high concentrations of albumin in the plasma decreases ESR.

The presence of high concentrations of cholesterol in the plasma increases ESR.

2. Red Cell Factors:

Anemia increases the ESR, because the change in the erythrocyte plasma ratio, which is a
feature of anemia, favors rouleaux formation.

Microcytes sediment slower than macrocytes.

Rouleaux formation accelerates the ESR.

Red cells with an abnormal shape (e.g. spherocytes, sickle cells), delay rouleaux
formation and lower the ESR.

**. Method:

The procedure widely in use is a modified method of the original Westergren method.

1. Principle:

When well-mixed venous blood is placed in a vertical tube, erythrocytes will tend to fall
toward the bottom. The length of fall of the top of the column of erythrocytes in a given
interval of time is called the ESR.

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 GHOR ALSAFI LAB. ESR
2. Equipment:
2.1. Collection Tubes:

Sodium citrate is used as the anticoagulant.

The ESR citrated tube contains 0.11 mmol/L sodium citrate.

The final blood to citrate ratio in the tube is: 4:1.

2.2. The Westergren Pipette:

The Westergren pipette is a straight pipette 30 cm long, 2.55 millimeters (mm) in internal
diameter, and calibrated from 0 to 200 mm. The bore must be uniform to 0.05 mm
throughout.

The volume of the pipette is 1 mL.

The pipette must be clean, dry and dust free.

2.3. The Westergren Rack:

The Westergren rack must allow an exactly vertical pipette position.

3. Procedure:

Procedure for ESR

1. It is recommended to set up ESR at room temperature (20-250C).
2. Add 2 mL of whole blood to 0.5 mL of sodium citrate and mix by inversion, or
add 1 mL of whole blood to 0.25 mL of sodium citrate and mix by inversion.
3. Mix the blood sample thoroughly (preferably on a roller mixer if available) and
then draw it up into the ESR pipette.
4. Fill the pipette to the 0 mark and place it exactly vertical in the ESR rack at room
temperature free from vibration, draughts or exposure to direct sunlight.
5. After exactly 60 minutes, read the height of the clear plasma above the upper
limit of the column of sedimenting cells, i.e., the distance from the 0 mark to the
top of the column of red cells is recorded in millimeters and this is the ESR
value.
If the demarcation between plasma and red cell column is hazy, the level is taken
where the full density is first apparent.
6. If the temperature is outside the recommended range (less/more than 20-250C), a
temperature correction chart should be used.

**. Quality Control:

Perform a quality control check whenever routine ESR tests are performed.

When comparing between two different methods, select one blood sample with a
Hematocrit value between 0.3 and 0.36 and perform ESR testing on it on both
methods.

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 GHOR ALSAFI LAB. ESR

**. Technical Sources of Errors:

The presence of clots or bubbles in the pipette or collection tube will affect the ESR.

If the concentration of sodium citrate is higher than recommended, the ESR may be
elevated.

Incorrect positioning of the tube: the ESR is increased if the tube is not vertical. Tilting
the tube accelerates the ESR; red cells aggregate along the lower side while the plasma
rises along the upper side. An angle of even 3 degrees from the vertical position may
accelerate the ESR by as much as 30%.

Variation in Temperature: temperature should be within the range of 200C-250C. Lower
temperatures decrease the ESR, while higher temperatures increase the ESR. If the blood
has been kept refrigerated, it should be allowed to reach room temperature and mixed by
inversion a minimum of eight times before the test is performed.

The test should be performed within two hours after the blood is collected; otherwise,
some samples with elevated ESR will be falsely low. On standing, erythrocytes tend to
become spherical and less readily form rouleaux.

If leakage from the pipette upon standing occurred, the test result is invalid and the test
should be repeated.

When reading the result, if a poor delineation of the upper layer of red cells was noticed,
the presence of many reticulocytes should be suspected.

**. Special Considerations:

Hemolysis may change the rate of sedimentation.

Heparin cannot be used as an anticoagulant.

Heparin can increase the ESR when used as a medication.

Plastic ESR pipettes have a slightly higher (1 to 2 mm/hour) values than glass.

***. Critical Elements of Competence for Evaluation

Understanding of the pre-analytical conditions of the test: specimen collection,

appropriate anticoagulant for specimen collection, and storage.

Ability to perform the proper technique of ESR determination.

Understanding of the special considerations and technical notes related to the analytical
as well as the pre-analytical steps.

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